Surgery Station 1-4

Station 1
Abdominal Surgery Clinical task
1 A 35-year-old patient was taken by an ambulance with complaints of general weakness,

dizziness and stool with tarry feces. This morning, when he got out of bed, he lost
consciousness for a few seconds. According to the anamnesis: periodically for three years
disturbs pain in the epigastric region, especially at night, heartburn. For two weeks before
admission, there is an increase in pain, which passed on its own two days ago. On
examination, the skin is pale, blood pressure 90/60, pulse 110 per 1 min, the abdomen is not
bloated, soft, almost painless, symptoms of peritoneal irritation are negative. Intestinal
peristaltic is increased. Urgent EGDFS - on the posterior wall of the duodenum wall defect,
covered with a red clot, blood leaks.
1. Peptic ulcer of the duodenum. Acute gastrointestinal bleeding.

Hemorrhagic shock AI degree.
2. Wedge. Blood test: erythropenia, depose hemoglobin
coagulogram
FGDS main diagnostic study; predominantly visualizes the place
bleeding, allows you to evaluate its intensity and begin
treatment. Classification
the intensity of bleeding from an ulcer, after Forest and singing.: degree I -
active
pulsating bleeding (Ia) or leak (and b) Iia - the vessel does not bleed
noticeably; IIb, -
blood clot at the bottom of the ulcer IIc - the painted bottom of the ulcer III
- the white bottom of the ulcer.
3. If necessary, intubation (risk of aspiration), oxygen therapy.
Constant blood pressure monitoring
Hemorrhage stop: aminocaproic kta 6% 100 ml, or 10 mg / kg Tranexam
kta, 1-2
mg of vitamin K. Surgical stop of bleeding during FGDS (chipping
vasoconstrictor or obliterating vessels (sclerotherapy) drugs,
electrocoagulation,
argon plasma coagulation).
Peripheral vein catherization. Infusion therapy (3 ml crystalloid per 1 ml
lost blood, or 1 ml of colloid per 1 ml of blood, with significant blood loss -
erythrocyte mass)
IPP - omeprazole, esomeprazole, pantoprazole injection
Vagotomy with closure of a bleeding ulcer
Clinical task 2
A 58-year-old man 2 hours after the first vomiting was taken by an ambulance with
complaints of weakness, vomiting with blood impurities. The patient suffered from chronic
gastroduodenitis for 10 years. I have lost weight in the last year. Appetite decreased,
aversion to meat eating. On examination, the skin is pale, blood pressure 100/70, pulse 100
per 1 min, the abdomen is not bloated, soft, moderately painful in the epigastrium, no
symptoms of peritoneal irritation. Peristaltic intestinal murmurs are amplified. In the left
supraclavicular area dense elastic formation up to 1.5 cm in diameter. Urgent EGDFS - on a
small curvature of a stomach the defect of a wall covered with fibrin to 3 cm, rigid wall,
blood leak
1. Cancer is a stomach ulcer. Acute gastrointestinal bleeding. Hemorrhagic shock II

century.
2. Wedge blood test - anemia, BH - hypoproteinemia
EFGDS + targeted biopsy, stopping bleeding
Radiologically - a niche would be 2cm - malignancy, irregular relief
Ultrasound of organs through an empty stomach
CT
3. Treatment of hemorrhagic shock:
Hemorrhage stop: aminocaproic kta 6% 100 ml, or 10 mg / kg, tranexam kta, 1-
2 mg of vitamin K. Surgical stopping of bleeding during FGDS (chipping
vasoconstrictor or obliterating vessels (sclerotherapy) drugs, electrocoagulation,
erythrocyte mass)
4. Cancer treatment: (depending on the prevalence of the process) gastrectomy,
gastrectomy with regional lymph nodes affected by neighboring organs,
endoscopic mucosal resection, palliative techniques.
Chemotherapy, radiation therapy
Clinical task 3
The builder of 35 years during the last 6 months notes weight in an epigastric
site. Not examined. He had abused by alcohol the night before. At night there
was double vomiting, and in the morning after a slight physical exertion there
was dizziness and hematemesis near to 1000 ml. Immediately sought help and
was taken by an ambulance with complaints of weakness. On examination, the
skin is pale, blood pressure 105/70, pulse 96 per 1 min, the abdomen is not
bloated, soft, moderately painful in the epigastrium, symptoms of peritoneal
irritation are negative. Intestinal peristaltic is increased. Urgent EGDFS - in the
cardiac stomach - superficial linear ruptures of the mucosa up to 2-3 cm, blood
leaks
1) Gastroesophageal rupture and hemorrhagic syndrome (with Indra Malori - Weiss
)
Mallory-Weiss syndrome - rupture of the mucous membrane of the cardiac section of
the stomach and
fundus of the stomach. It manifests itself as internal bleeding, repeated vomiting. Often
observed in people who abuse alcohol.
2) Diagnostics
Hematomesis - bloody vomiting
a.
FEGDS (identification of longitudinal ruptures of the mucous membrane 2-4 cm long,
located longitudinally with respect to the axis of the esophagus and stomach, localized
mainly on the border between the esophagus and the cardia)
b.
Chest x-ray (to exclude
pulmonary hemorrhage)
c.
Laboratory: General blood test (detection of a decrease in hemoglobin, red blood cells)
biochemical blood test (determination of creatinine, urea, total protein,
gas and electrolyte composition of blood) coagulogram; blood type and rhesus
factor a; analysis of feces for Gregersen's reaction (analysis of feces for occult blood)
3) Bleeding can be stopped in various ways, including coagulation with
the use of an EHF generator, a laser, an argon plasma setup, etc., by introducing
hemostatic drugs injector irrigation zone various
hemostatic.
Hemostatic therapy - Ethamsylate 250-750 mg per 200 ml of isotonic sodium chloride iv
drip; Aminocaproic acid 10 mg orally during the day; Tranexamic acid - 1 g
every 8 hours iv for 3 days in the absence of complications
Blood loss correction - saline solutions or, in the case of significant blood loss and
violation of coagulation, plasma, red blood cell mass, platelet mass.
Inhibition of gastric secretion - PPI (omeprazole iv drip 40 mg), iv blockers H2-
receptors (famotidine intravenously or 40 mg jet every 6-8 hours)
If bleeding did not stop with conservative treatment, then surgical
treatment: Endoscopic hemostasis (thermocoagulation or targeted injection)
Angiographic intervention: selective infusion of vasopressin in the left gastric
artery or embolization) Tamponade using an esophageal probe; With ongoing
bleeding - surgery to flash the site of bleeding
Clinical task 4
The patient is 38 years old, complains of frequent liquid stools (up to 4 times), with periodic addition
of blood and mucus, cramping pain along the colon. Ill for about 4 months after the stress, on the last
day, according to the words, the total volume of stool is to 1.0 liter with blood. He was treated with
“Loperamide”, but did not conduct additional examinations. Objectively: low nutrition, pale skin,
blood pressure 100/70, pulse 100 per 1 min, abdomen not bloated, soft, no symptoms of peritoneal
irritation, moderate palpation pain in the left iliac region. Conducted urgent examination: Er-
2,8x1012 / l, HB - 80 g / l, ESR - 28 mm / h, total. protein - 65 g / l. Colonoscopy - diffuse hyperemia of
the mucous membrane, erosions, numerous superficial ulcers with layers of fibrin, mucus and fresh
blood
1- ulcerative colitis
2 Diagnostics
a.
Clinic, symptoms
b.
Laboratory: General blood test (detection of a decrease in hemoglobin, red blood cells,
leukocytosis, LF shifts to the left, increased ESR) blood chemistry
(hypoalbuminemia, increased concentration of β-globulins and γ-globulins) disturbances in
water
electrolyte balance, hypokalemia
c.
Instrumental: Irrigography (inequality and granularity of the mucous membrane,
pseudopolyposis, ulcers, lack of haustration, shortening of the intestine, its narrowing,
absence
contrast medium in the affected area), colonoscopy (for hyperemia, swelling,
granularity of the mucous membrane to ulcers, pseudopolyposis and the presence of pus and
blood in the lumen
intestines), histological examination (atrophy of the mucous membrane, leukocyte
infiltration, the creation of microabscesses)
3) Treatment
● Eriotropic therapy with the exception of exogenous and endogenous factors
● Pathogenetic therapy
Glucocorticosteroids
Cytostatics
- Preparations containing 5-PASK
Antidiarrheals, astringents, adsorbing preparations
antibacterial therapy
-Treatment of dysbiosis
● symptomatic therapy |
Detoxification therapy
Correction of metabolic disorders and anemia
-Treatment of proctosigmoiditis
- Restore central nervous system function
● Physiotherapy |
● Spa treatment
● Prevention
I. Acute phase:
● mesalazine in suppositories 0.5 g 4 times (or 1 g 2 times a day) orally;
● prednisone 10 mg (in suppositories) 2-3 times a day;
● an enema with quercetin, 1 g per 1/2 cup of water or 50-100 ml of a 0.05% solution of
collargol;
● enema with the collection of herbs with anti-inflammatory effect (1 tablespoon of the
collection in 1 glass
water);
● symptomatic treatment of diarrhea (diosmectitis, loperamide, astringents, painkillers
facilities).
Remission phase: the same drugs (half the dose) + enemas.
AI. Treatment of ulcerative proctosigmoiditis during the active phase:
● prednisolone 20 mg iv for 1 month, followed by enemas with prednisolone (30 mg) or
hydrocortisone (125 mg)
● mesalazine 2 g once daily for + suppositories;
● correction of electrolyte and protein disorders;
● enemas with mesalazine 4 g per day + suppositories daily + enemas with quercetin or
collargol;
● antidiarrheal agents (loperamide 2 mg 1-2 times a day), astringents (tanalbine 0.5 g
3 times a day), enterosorbents (hydrogel of methylsilicic acid, nanosilicon dioxide,
Activated carbon);
● prokinetics (domperidone), antispasmodics (drotaverine).
III. Treatment of ulcerative left-sided colitis during the active phase
Easy move:
● sulfasalazine 3-4 g / day;
● mesalazine 2-3 g / day;
● local treatment with microclysters.
Moderate form:
● prednisone at 40-60 mg / day + local treatment with microclysters;
● sulfasalazine 4-6 g / day or mesalazine 4 g / day;
● metronidazole 1 g per day for 20-30 days
● after suppression of pathogenic flora, re-implantation of the normal intestinal flora
the microbial mass of live strains (antagonistically active) of E. coli (E. coli) and
bifidobacteria (B. bifidum), with bacilli of strain Bacillus cereus IP 5832 with vegetative
spores in
within 2-3 months;
● detoxification therapy, replacement therapy (combination drug containing
amylase, protease and lipase, pancreatin).
IV. Severe: treatment is the same as with total colitis.
V. treatment of total NIAC in the acute severe (fulminant) phase:
● complete parenteral nutrition (protein - 1.5-2.0 g / kg body weight, calorie content - not less
than 4 kcal /
kg);
● hydrocortisone 200-300 mg iv for 2 days, then IM for 5-7 days with a gradual dose
reduction by
20-30 mg / day and the transition to oral prednisone at a dose of 40-60 mg / day
● antibiotic therapy: cephalosporins of the II-III generation, nitroimidazoles with anaerobic
infections
● rectal administration of hydrocortisone at 100 mg (per 100 ml of water) 2-3 times a day;
● preparations of 5-aminosalicylic acid from the 5-7th day, provided that the conservative is
successful
therapies
● with a resistant form of school - cyclosporine at a dose of 4-5 mg / kg / day iv or 5-15 mg /
kg / day
orally or infliximab at a dose of 5-10 mg / kg / day for 14 days.
V and. Treatment of a chronic and inactive form of CDD:
● prednisone at a dose of 40-50 mg / day according to the scheme of gradual dose reduction in
combination with mesalazine
2-4 g / day;
● in case of resistance to 5-aminosalicylic acid, HA is prescribed, cytostatics of azathioprine
in
dose of 2 mg / kg / day or infliximab.
VII. surgery
● Surgical treatment is used in case of perforation, intestinal obstruction and
bleeding, abscess, progressive toxic dilatation of the colon wall (when
conservative therapy for 12-14 hours is ineffective). With rapidly progressing and
resistant forms of the disease perform colectomy with ileoanal anastomosis and
the formation of the tank
Clinical task 5
Patient K., 27 years old, a military, complains of constant pain in the right iliac region (often wakes up
at night from pain), periodically there are attacks of pain such as colic. He worried about severe
weakness, diarrhea - stool 3-4 times a day in the form of a liquid slurry, in the last week - with blood,
profuse. Notes a rise in temperature to 37.6 ° C daily, especially in the evening. History: Ill 1 year ago,
when suddenly there was intense pain in the right iliac region, fever up to 38.0 ° C. The patient
underwent appendectomy. In the postoperative period, hyperthermia appeared up to 38.5 ° C, on
the background of the introduction of antibiotics, the temperature dropped to subfebrile fig ures, but
did not disappear completely. During the year of the disease, the patient lost 6 kg. Objectively:
reduced nutrition, the skin is somewhat dry, turgor is reduced. Peripheral lymph nodes are not
palpable. Pulse - 96 / min, blood pressure - 100/70 mm Hg. The abdomen is involved in breathing,
the usual configuration. At a palpation - pain in the right iliac area where the dense painful caecum
and a little above inflated grumpy loops of a small bowel are palpated. There are no symptoms of
peritoneal irritation. General blood test: hemoglobin - 96 g / l, ESR - 34 mm / h, erythrocytes - 2.8 ×
1012 / l, leukocytes - 12.6 × 109 / l, eosinophils - 2%, neutrophils - 61%, lymphocytes - 37%.
Biochemical analysis of blood: total protein - 52 g / l. Irrigoscopy: barium suspension retrogradely fills
all parts of the colon and for 15- 20 cm of ileum, there are irregular narrowing of the distal ileum and
irregular contours, absence of gaustra in the cecum and ascending colon.
1-diagnosis
Crohn's disease
2 Diagnostics
d.
Clinic, with an objective examination, detect pain in the right iliac
areas where a dense, motionless, painful formation with fuzzy is often palpated
contours (inflammatory infiltrate)
e.
Instrumental diagnostics: X-ray examination of the esophagus, stomach,
duodenum, small and large intestine (segmental or multifocal
lesions, characterized by a long asymmetric stricture with negligible
parietal dilation, straightening of the affected area (symptom of "string"), along the edges of
the niche
different sizes, ulcers merging over which the mucous membrane protrudes (symptom
"Pavement"), shortening the changed sections; irrigoscopy (absence of haustres) endoscopic
research - FGDS, intestinoscopy, sigmoidoscopy, colonoscopy (submucosal swelling
layer, lack of vascular pattern, small aphthae in the infiltrative phase of the process, deep
slit-like cracks, relief of the mucosa according to the type of “cobblestone pavement”,
strictures, alternation
affected areas with intact.
f.
Laboratory: general blood test (anemia, leukocytosis, increased ESR, increase
platelet count), biochemical blood test (hypoalbuminemia, high activity
CRP), a high concentration of ferritin, transferrin, a decrease in concentration B
12
folic
acids, zinc and magnesium.
g.
Histological examination: on the forum of pathognomonic histological signs; at
60% of cases in the intestinal wall are noncaseating granulomas from giant epithelioid cells
multinucleated cells such as Pirogov-Langhans and lymphocytes.
3 Treatment
- Diet - from the diet exclude products that can provoke an exacerbation -
lactose, sucrose, coarse dietary fiber. Increase the number of products
restore deficiency of iron, folic acid, vitamin B
12
zinc, calcium and
magnesium.
- Drug treatment
1.
Symptomatic therapy of pain, diarrhea, anemia
2.
Anti-inflammatory therapy with salicylates (sulvasalazine 2-4g / day for lesions
colon, mesalazine 1.2-3.2 g / day with small intestinal localization), metronidazole 1.5 g /
day, ciprofloxacin 0.5-1.0 g / day
3.
Immunosuppressants - prednisone 160-240 mg / day, hydrocortisone 300-450 mg / day,
azathioprine up to 200 IU / day, cyclosporine 4 mg / kg body weight per day
4.
Immunomodulation using an anti-cytokine strategy aimed at blocking
individual modulators of inflammation, the use of anti-inflammatory regulatory cytokines
(monoclonal antibodies to TNF, CD4 +, recombinant interferon preparations)
5.
surgery
1. Indications:
1) urgent (immediate operation) - total obstruction due to narrowing of the thin
intestines, massive bleeding, perforation with diffuse peritonitis;
2) urgent - the lack of obvious improvement within 7-10 days of intensive conservative
treating severe relapse of extensive colon damage;
3) selective (frequent) - external and internal fistulas, infectious intraperitoneal
complications, extensive perianal changes, cancer diagnosis, or cancer suspicion,
long-term disability due to persistent unpleasant symptoms, despite adequate
conservative treatment, retardation of physical development with growth inhibition in
children.
2. Types of operations:
1) diseases of the small intestine → economical resection or
intraoperative dilatation of narrowing of the small intestine
(stricturoplasty)
2) diseases of the right or left half of the colon →
hemicolectomy;
3) more extensive changes in the colon → colectomy with
the formation of an ileorectal anastomosis or proctolectomy with
the formation of a permanent ileostomy.
Clinical task 6
The 72-year-old patient complains of sharp cramping pain in the left half of the abdomen, nausea,
delayed defecation and gas. He is ill 6 hours, after prolonged hard physical work. There were no
operations. In anamnesis - constipation during the last 20 years. I did not notice any impurities of
mucus and blood in the stool, I did not lose weight. Pulse rate - 84 / min. The tongue is moderately
dry. The abdomen is sharply swollen, asymmetrical due to the increase of the left half, which
determines the positive Val symptom. Peristaltic noises are periodically amplified, the noise of a
splash. Per rectum - a symptom of Obukhov hospital.
1-diagnosis
Acute intestinal obstruction ( strangulation)
Symptom Valya (Wahl): asymmetry of the abdomen due to overstretched intestinal loop,
percussion over
her tall tympanite
Symptom of the Obukhov hospital (Grekov): with digital rectal examination is determined
relaxation of the sphincter of the rectum and empty ampoule. Typical for low obstruction
intestines
Diagnostic algorithm for examining a patient
1.
General analysis of peripheral blood: increasing in proportion to degree
hematocrit dehydration and an increase in the number of red blood cells; in case of intestinal
necrosis -
sudden increase in white blood cell count.
2.
Biochemical blood test: it is necessary to determine the level of sodium and potassium,
indicators
renal function and gas composition of arterial blood, since obstruction may
there are water-electrolyte disturbances, renal failure and acidosis.
3.
Survey RG of the abdominal cavity in a standing position or lying on its side (seriously ill)
with
using side x-rays can detect fluid levels in inflated loops
intestines - slowing the passage of intestinal contents leads to the separation of liquid
gaseous fractions;
4.
CT scan of the abdomen can reveal the likely cause and level of obstruction.
5.
Endoscopic examination of the large intestine: can visualize the level
obstruction. If the obstruction is incomplete, you can sometimes enter the end of the
endoscope
higher and decompression, which should facilitate the preparation of the patient for final
surgical operation. The decision on such tactics is made by the surgeon.
surgical treatment
1.
Elimination of obstacles for passage.
2.
Elimination of the disease resulting in obstruction.
3.
Non-viable bowel resection.
4.
Prevention of an increase in endotoxemia in the postoperative period.
5.
Prevention of relapse obstruction
Clinical task 7
A patient was brought to the admission department with complaints of bloating, cramping pain,
nausea, vomiting, dry mouth, which bothered him for 8 hours. From the anamnesis we see that 3
years ago he underwent surgery for a closed abdominal injury, a splenectomy was performed.
Objectively: the skin is moderately pale; the tongue is dry, covered with gray layers. The abdomen is
asymmetrically enlarged, a colloid scar is expressed along the midline after the upper-middle
laparotomy, the mobility of the anterior abdominal wall is determined, which smoothly changes the
location. Palpation: pain, positive symptoms of Mondor, Val, Solyarov; percussion - the symptom of
Kivul is defined.
1-diagnosis
Acute intestinal obstruction
Symptom Valya (Wahl): asymmetry of the abdomen due to overstretched intestinal loop,
percussion over
her tall tympanite
Sklyarov’s symptom (“splashing noise”) is determined by jerky palpation with one or two
hands located in the lateral abdomen or jerky movements with one hand
while listening to the abdomen with a phonendoscope.
Symptom of Kiwull: a high tympanic sound with a metallic tinge over a swollen
loop of the intestine.
Diagnostic algorithm for examining a patient
1. General analysis of peripheral blood: increasing in proportion to the degree
hematocrit dehydration and an increase in the number of red blood cells; in case of intestinal
necrosis
- sudden increase in white blood cell count.
2. Biochemical blood test: it is necessary to determine the level of sodium and potassium,
indicators
kidney function and gas composition of arterial blood, as a consequence of obstruction
there may be water-electrolyte disturbances, renal failure and acidosis.
3. Survey RG of the abdominal cavity in a standing position or lying on its side (seriously ill)
with
using lateral x-rays can detect fluid levels in bloated
intestinal loops - slowing the passage of intestinal contents leads
separation of the liquid fraction from the gaseous;
4. CT scan of the abdominal cavity can identify the likely cause and level of obstruction.
5. Endoscopic examination of the large intestine: can visualize the level
obstruction. If the obstruction is incomplete, sometimes you can enter the final part
the endoscope is higher and decompress, which should facilitate the preparation of the patient
for
final surgery. The decision on such tactics is made by the surgeon.
surgical treatment
1. Elimination of obstacles for passage.
2. Elimination of the disease resulting in obstruction.
3. Resection of a non-viable colon.
4. Prevention of an increase in endotoxemia in the postoperative period.
5. Prevention of relapse obstruction.
Clinical task 8
A 68-year-old patient complains of cramping pain and bloating, delayed defecation and gas for 4
days. During 6 months he notes alternately constipation and diarrhea, over the last month
periodically appear mucus and streaks of blood in the stool, lost 5 kg.
1 diagnosis
Colorectal cancer (CRC) - a medical definition of a malignant tumor of the mucous
membrane
colon (columns) or rectum (rectum).
Localization during colonoscopy ( colon formation)
Analysis abnormalities: Blood ↓ HB, ↓ Er, ↑ Lake, ↑↑↑ ESR
BH: ↑ total Bel. ↑ Urea,
Urine: N
Diagnostic algorithm for examining a patient with suspected CRC
- Complaints of the patient and anamnesis.
-clinical examination, digital examination of the rectum;
endoscopic examination of the colon (sigmoidoscopy or
colonoscopy) with tumor biopsy;
X-ray of the colon with barium contrast;
-endorectal ultrasonography for tumors of the rectum;
Ultrasound / CT scan of the liver
CT / MRI of the pelvis with a fixed tumor of the rectum;
X-ray of the chest organs (if necessary CT)
laboratory tests, including determination of serum CEA levels
blood
TREATMENT
Localized tumor (colon):
Stage 0 (Tis N0 M0, T1 N0 M0)
• Local excision or polypectomy
• Segmental resection
Stage I (T2N0M0)
• Wide resection with anastomosis (right - or left-sided
hemicolectomy)
Stage II (T3N0M0, T4N0M0)
• Wide resection with anastomosis. In the presence of factors
risk for the patient, adjuvant chemotherapy is possible.
Stage III (any T, N1M0, any T, N2M0)
• Wide resection with anastomosis. After surgery, the standard is
conducting adjuvant chemotherapy. [5]
Today, indications for adjuvant chemotherapy in patients
colorectal cancer is stage III disease (Dukes C).
Localized tumor (rectum):
• Mandatory preoperative exposure. [6]
• In case of damage to the rectum, chemoradiation treatments are used,
due to the high sensitivity of the tumor to radiation therapy. in case of defeat
colon - only chemotherapy. [12]
• Operations: sphincterosomes (in / 3, s / 3), cervical-anal resection (n / 3,
anal canal).
Clinical task 9
The patient 35-year-old was taken by an ambulance with complaints of general weakness, dizziness,
and stool with tarry feces. This morning, when he got out of bed, he lost consciousness for a few
seconds. According to the anamnesis: periodically for three years, pain in the epigastric region,
especially at night, heartburn. For two weeks before admission, he noted an increase in pain, which
passed on its own two days ago, and the above complaints appeared. On examination, the skin is
pale, blood pressure 90/60, pulse 110 per 1 min, heart sounds are muffled, the abdomen is not
bloated, soft, almost painless, no symptoms of peritoneal irritation. Peristaltic intestinal murmurs are
amplified. Urgent EGDFS - on the posterior wall of the duodenum defect of the wall, covered with a
red convolution, blood leaks
1. Peptic ulcer of the duodenum. Acute gastrointestinal bleeding.

Hemorrhagic shock AI degree.
2. Wedge. Blood test: erythropenia, depose hemoglobin
coagulogram
FGDS main diagnostic study; predominantly visualizes the place
bleeding, allows you to evaluate its intensity and begin
treatment. Classification
the intensity of bleeding from an ulcer, after Forest and singing.: degree I -
active
pulsating bleeding (Ia) or leak (and b) Iia - the vessel does not bleed
noticeably; IIb, -
blood clot at the bottom of the ulcer IIc - the painted bottom of the ulcer III
- the white bottom of the ulcer.
3. If necessary, intubation (risk of aspiration), oxygen therapy.
Constant blood pressure monitoring
Hemorrhage stop: aminocaproic kta 6% 100 ml, or 10 mg / kg Tranexam
kta, 1-2
mg of vitamin K. Surgical stop of bleeding during FGDS (chipping
vasoconstrictor or obliterating vessels (sclerotherapy) drugs,
electrocoagulation,
erythrocyte mass)
IPP - omeprazole, esomeprazole, pantoprazole injection
Vagotomy with closure of a bleeding ulcer
Clinical task 10
The patients 37-year-old railway depot worker was taken to hospital 40 minutes after the injury.
According to the patient: he was injured during repair work when he was suddenly trapped in a
standing position, between a wall and a load that was not fixed and shifted. At clinical examination in
the admission department: the patient is conscious. Complains of pain and swelling in the upper arm
on the right, which is exacerbated by movements in the right shoulder. During the examination,
constantly trying to sit on the couch. According to the patient: in the supine position there is a feeling
of fullness in the abdomen, there is intense pain in the lower chest on the right side which gives in
the neck. The chest is symmetrical, evenly participates in the act of breathing. At a palpation and
percussion of a thorax pain and encryption is not defined. When you press on the lower part of the
sternum, there is pain along the right half of the costal arch. Auscultatory: vesicular respiration in the
lungs, no wheezing. Nasal breathing, 22 per minute. Heart tones are clear, rhythmic. AT 130/80 mm
Hg Pulse 90 per minute, rhythmic, satisfactory filling. The abdomen is symmetrically swollen. On
palpation, local pain and muscle rigidity in the right hypochondrium. At percussion of this site there is
a sharp pain. Blumberg's symptom is negative. Auscultatory: peristaltic noises are active, are heard in
all departments of an abdominal cavity. Rectal - sphincter in normotonus, the study is not painful.
During the two-hour examination and observation, the patient's condition did not worsen.
1) Traumatic lesion of the parenchymal organ (liver).

2) The following symptoms are observed: Rozanova (when the patient is horizontal, pain
occurs
in the area of the right shoulder girdle and shortness of breath, so he takes a half-sitting
position),
Khedra (when pressing the lower part of the sternum with a liver injury, pain occurs
along the right
costal arch), Eleker (pain radiating to the right shoulder girdle).
Laboratory: a decrease in the number of red blood cells, hemoglobin, leukocytosis, an
increase in AlAT, AsAT.
X-ray and fluoroscopy - there may be a high placement of the right dome of the
diaphragm, its
"ragged contour", rib fracture, disk-shaped atelectasis of the basal segments of the right
lung,
the presence of fluid in the abdominal cavity.
Ultrasound of the liver - evaluate the surface and structure of the liver, contours,
diameter, vascular patency
liver (portal vein, hepatic veins, arteries) and biliary structures. Using ultrasound
liver damage is found in 93% of injured: "parenchymal syndrome
damage "- in 80.5%," intra-abdominal bleeding syndrome "- in 91.6%. In case of injury
- the zone
increased echogenicity, uneven contours of the body.
Informative is angiography (via the femoral artery with Seldinger), which allows
detect damage to the vessels of the liver and / or the accumulation of contrast medium
(extravasate) in
the site of intraorgan hematoma.
In the early diagnosis of a catastrophe in case of abdominal injury, the method of choice
is laparocentesis
immediately after hospitalization. Moreover, if more than 20 ml of hemorrhagic
fluids then perform laparotomy. For the diagnosis of closed liver damage
it is advisable to use the "gold standard": laparocentesis with peritoneal lavage;
ultrasound procedure; laparoscopy.
3) Treatment depends on the condition of the patient. Indications for conservative
management of the patient
stable hemodynamics, moderate hypotension (blood pres sure less than 120, but more
than 90 mm Hg. Art.), stable
indicators of Hb and Ht, hemoperitonsum up to 500 ml, small liver damage, superficial
rupture, minor bleeding, no data on damage to other organs.
The tactic is that you need a strict bed rest, local hypothermia,
drug therapy: intensive infusion-transfusion, hemostatic therapy,
Antibiotic prophylaxis, hepatoprotectors, stimulation of intestinal motility, prevention
and treatment of injury complications, careful dynamic monitoring of the condition
injured.
Indications for surgery: there is a reasonable suspicion or is diagnosed
damage to other organs of the abdomen, severe symptoms of peritonitis, the presence of
fluid in
abdominal cavity with a thickness of 2 cm or more (ultrasound data) and unstable
hemodynamics (blood pressure <100 mm
Hg. Art.) when performing laparocentesis (abdominal lavage) received 20 ml of blood.
In this case, the removal of non-viable parenchyma tissues, hemostasis, drainage are
performed
Clinical task 11
The patient, 42 years old, after treatment in the surgical department complains of general weakness,
sweating, which occurred 5 days ago and gradually began to increase. Worried dry cough, moderate
intermittent chest pain on the right, which is exacerbated by deep breathing and gives the right.
Periodically fever. The temperature during these 5 days ranged from 37.5 0 C to 39.8 0 C. Operated
for chronic peptic ulcer disease of the duodenum, complicated by perforation. The chest is
symmetrical, evenly participates in the act of breathing. At a palpation and percussion of a thorax
pain and crepitation is not defined. Auscultatory: in the lungs, vesicular respiration, weakened right,
in the basal parts - not audible. Single dry rales on both sides. Percussion shortening of the lung
sound on the right. Respiratory rate 23 per minute, nasal breathing. Heart tones are clear, rhythmic.
АТ 120/80 мм.рт.ст. Pulse 88 per minute, satisfactory tension, filling, rhythmic. The anterior
abdominal wall is involved in the act of breathing. Palpation soft. Deep palpation reveals local pain in
the right hypochondrium. When percussion with the fingertips, in this area, there is a moderate, dull
pain that radiates to the right half of the chest. The border of the liver does not extend beyond the
edge of the costal arch. The spleen is not palpable. Blumberg's symptom is negative. Auscultatory:
peristaltic noises are active, are heard in all departments of an abdominal cavity
1) Subphrenic abscess.
2) Laboratory: leukocytosis with a shift of the formula to the left; acceleration of SCHOE, -
hypo-dysproteinemia,
an increase in the concentration of urea, creatinine, the appearance of C-reactive protein.
X-ray examination of the organs of the chest and abdominal cavities: high standing and
restriction of mobility of the dome of the diaphragm, the presence of a liquid level under the
diaphragm, in the lungs -
atelectasis, effusion in the pleural cavity on the side of the lesion.
Ultrasound of the abdominal cavity allows you to confirm the presence of fluid, pus and gas
in the abdominal or
pleural cavity, a change in the position and condition of adjacent internal organs.
3) The main treatment method is surgical (adequate drainage of the percutaneous abscess
puncture under ultrasound control or by surgery), at the same time prescribe antibacterial
therapy: broad-spectrum antibiotics depending on the results of bacteriological
research and determination of the sensitivity of microorganisms to antibiotics.
If surgical treatment, then transthoracic (transpleural) or trans pain
opening a subphrenic abscess and removing manure from its cavity. Then the cavity is washed
antiseptic agents and establish drainage with suturing the wound.
Clinical task 12
The patient, 52 years old, complains of general weakness, sweating, fever from 37.5 0 C to 38.5 0 C,
which occurred 7 days ago. At the time of examination, tenesmus, moderate intermittent pain during
defecation, frequent urination are disturbing. From the anamnesis it is known that a month ago she
was treated in the gynecological department for uterine fibroids. The chest is symmetrical, evenly
participates in the act of breathing. Breasts without pathological changes. At a palpation and
percussion of a thorax pain and crepitation is not defined. Auscultatory: vesicular respiration in the
lungs, no wheezing. Percussion; clear lung sound. Respiratory rate 20 per minute, nasal breathing.
Heart tones are clear, rhythmic. AT 130/90 mm. rt. Art. Pulse 82 per minute, satisfactory tension,
filling, rhythmic. The abdomen symmetrically participates in the act of breathing. On palpation, the
anterior abdominal wall is soft. Local pain over the womb is determined. When percussion with
fingertips over the womb dull pain that radiates to the perineum. Blumberg's symptom is negative.
Auscultatory - peristaltic noises without features. Rectally - the sphincter in hypertension, pelvic
Douglas space is filled with fluid, sharply painful.
Dıagnosıs
Pelvıc abcess
Surgery draınıng wıth ct or ultrasound wıth guıdance
Treatment antıboıtıcs broad spectrum
Laparoscopy
laparotomy
Clinical task 13
A woman 21-year-old went to the hospital with complaints of general weakness, dizziness, tinnitus,
and spontaneous pain in her left upper arm. Anamnestic: the condition worsened suddenly, in the
morning during exercise. On clinical examination, the skin and visible mucous membranes are pale,
covered with sticky sweat. On the skin of the upper and lower extremities, back, torso, numerous old
bruises, subcutaneous hematomas. The bruises appeared 7 days ago, after falling from a scooter.
During the examination, he constantly tries to sit on his back. The thorax is symmetrical, participates
in the act of breathing. No pathological changes were found on palpation and percussion of the
chest. Auscultatory: vesicular respiration in the lungs, no wheezing. Respiration rate 24 per minute.
Heart tones are muffled, rhythmic. AT 90/60 mm. rt. Art. Pulse 96 per minute, low voltage,
satisfactory filling, rhythmic. The anterior abdominal wall is involved in the act of breathing. On
superficial palpation, the abdomen is soft but slightly painful in the left hypochondrium and above
the womb. At percussion the dulling of a percussion sound along the left lateral channel is defined.
When the patient returns from the left to the right side, the dullness of the percussion sound moves,
and the dullness zone in the left hypochondrium is preserved. Auscultatory: peristaltic noises are
preserved. Rectal - sphincter in hypertension, the study is painful, a feeling of fluctuation in the
Douglas space. On the glove, the remains of feces are light Brown
1. Diagnosis: Traumatic damage to the parenchymal organs, trauma to the spleen (rupture).
2. diagnostics:
● + symptom of “Roly-stand”, Galans, Joyce, Khedr.
● Ultrasound (an increase in the size of the organ; the inequality of the fuzziness of its
contours, "Syndrome
intra-abdominal bleeding ”(echo-negative shadows around the spleen, the presence of fluid in
abdominal cavity)
● X-ray (increased organ shadow due to blood clots eclipse of the left subphrenic
space and lateral canal ("intra-abdominal bleeding syndrome"); raised
the left dome of the diaphragm and its mobility is limited; displacement of the stomach and
colon
gut symptom of "floating loops" of the intestine).
● Angiography (aortoarteriosplenography) (lake of contrast medium under the capsule or in
spleen parenchyma; contrast fluid flows beyond the body).
● CT (size of the spleen; defects in it; the amount of blood loss).
● Laparocentesis.
● laparoscopy.
3. The treatment is carried out an emergency operation (suturing with an atraumatic needle
(fiber)
separate nodal seams, U-shaped, spiral twisting seam. If you cannot
organ - splenectomy). Sanitation of the abdominal cavity. Infusion and hemostatic therapy.
Hemodynamic stabilization - use blood substitutes or transfusion.
Antibacterial drugs (cephalosporins 3-4 generations). Analgesics
Clinical task 14
A solder was taken to the mobile hospital (mine-explorative accident). From the accompanying
documents that the vehicle in which he was blown up by a highexplosive projectile. He was found on
the board of an inverted car. On examination, the patient is in a supine position. Productive contact
is broken. Reacts to the voice by turning his head to the side. Paraorbital edema around the eyes.
From the right ear canal and nose, a sticky, light, odorless liquid is released. Crepitation is
determined on palpation of the neck and upper arms on palpation. Auscultatory: vesicular
respiration in the lungs, percussion - a clear lung sound. On the left - breathing is not heard,
percussion box sound. Respiratory rate 30 per minute, breathing through the mouth. Heart tones are
depressed, rhythmic. AT 90/60 mm. rt. Art. Pulse 120 per minute, low voltage, filling, rhythmic.
Partial pressure of carbon dioxide and oxygen in the peripheral blood: PCO2 50 mm. rt. Art. PO2 60
mm. rt. Art. The anterior abdominal wall is involved in the act of shallow breathing; muscle rigidity is
determined. With percussion - tympanitis in all parts of the abdomen, hepatic dullness is not defined.
Symptoms of peritoneal irritation cannot be determined (unconscious patient). Auscultatory:
peristaltic noises are weak, single. A bladder catheter was used to obtain 40 ml of urine over 3.5
hours. Rectal - determined by the sagging wall of the rectum and fluctuations.
Diagnosis Polytrauma Gastrointestinal perforation Open craniocerebral trauma subcutaneous

emphysema
pneumothorax acute renal insufficiency
An open craniocerebral trauma was established due to the fact that C is of the right auditory
the passage and nose are secreted by a sticky, light fluid without a smell diagnosis of
subcutaneous emphysema on the neck and
on the shoulders with palpation, crepitus is determined. The anterior abdominal wall is
involved in the act
breathing superficially, stiffness is determined; the diagnosis of pneumotrax with percussion
is
tympanitis in all parts of the abdomen, hepatic dullness is not determined acute renal failure
A catheter from the bladder received 3.5 ml of urine within 3.5 hours.
2 Gastrointestinal bleeding is examined by clinical blood tests to determine
hematocrit, bcc deficiency, general urine analysis, blood glucose, perform an ECG, determine
blood saturation, the patient is recommended a CT scan of the brain of the chest RG reveals
the presence of
air in the subcutaneous tissue of the neck and chest; also radiological symptoms
pneumothorax or perforation of the gastrointestinal tract (air under the dome of the diaphragm
with
abdominal WG).
Treatment method: ( analgesics , dehydration therapy, ganglion blockers, subcutaneous
emphysema with
concomitant pneumothorax may require active drainage. For the treatment of gostroy
nirkovoy deficiency mean diuretics - mannitol (10% solution at the rate of 1 g /
kg of patient’s body weight) or furosemide (Lasix) in sufficient quantity. Parenteral
administration of 40-
60 ml of a 20% glucose solution with 5-6 units of insulin, as well as 100-200 ml of a 4%
solution of bicarbonate
sodium. In more severe cases, extracorporeal hemodialysis () by or
peritoneal dialysis . These methods make it possible to cleanse the body of the accumulation
of nitrogenous
slag and leveling upset mineral and acid-base balance
Clinical task 15
Patient N., 25 years old, complains of frequent (10-15 per day) liquid stools with admixtures of blood
and mucus, pain in the left iliac region, fever up to 38.3 ° C, a sharp general weakness, dizziness,
emaciation. Violation of the stool is noted for 2 months, but 7 days ago there was blood in the stool.
Objectively: a condition of moderate severity. The skin is pale. The tongue is slightly covered with
white plaque. Abdomen is oval, slightly swollen. At a palpation: moderate pain in a site of descending
part of a large intestine is defined
Diagnosis
1 ulceratıve colitis, acute course of moderate severity.
The diagnosis of ulcerative colitis was established on the basis of characteristic
clinical manifestations - diarrhea mixed with mucus, blood for two months,
signs of rectal lesions of contact bleeding
2 Patient recommended: general urine blood test, biochemical blood tests
(Total protein, albumin, total bilirubin, direct and indirect bilirubin, glucose, total
cholesterol, AST, ALT, alkaline phosphatase, GGT, creatinine, CRP, iron,
histological examination of colon biopsy specimens, bacteriological
examination of feces abdominal ultrasound,
3 it is recommended not to eat foods that irritate the intestinal wall, as well as in the case of
diarrhea limit the use of milk, for all patients it is recommended to limit
the use of coarse fiber .
basic therapy, which includes derivatives of aminosalicylic acid and GCS hormones,
cytostatics are also used to treat forms of the disease resistant to basic therapy
Clinical task 16
2. Patient K., 27 years old, a serviceman, complains of permanent pain in the right iliac region (often
wakes up at night with pain). There are periodically attacks of pain in the form of colic. He marks
severe weakness, loss of weight, diarrhea - defecation 3-4 times a day liquid porridge, without
pathological components, a fair amount. Notes a rise in temperature to 37.6 ° C daily, especially in
the evening. Anamnesis morbi: fell ill 1 year ago, when suddenly among the full health appeared
intense pain in the right iliac region, increased temperature to 38.0 ° C. In the emergency department
he was examined by a surgeon, acute appendicitis was diagnosed. The blood test revealed
leukocytosis. The patient was taken for surgery. The intraoperative revision revealed a thickened
ileum with a swollen wall, enlarged mesenteric lymph nodes. The appendix was not changed, but
appendectomy was performed. In the postoperative period, hyperthermia appeared up to 38.5 ° C.
After antibiotics the temperature decreased to subfebrile numbers, but did not disappear
completely. The pain in the right iliac region persisted, was moderate and constant. The patient
noticed increasing of defecation frequency, from 2 to 3-4 times a day. The fecal masses firstly had the
character of a thick porridge ("cow feces"), and then became liquid. Mucus and blood in small
quantities periodically appeared in the stool. Weakness gradually increased, during the year of the
disease the patient lost 6 kg of body weight. Objectively: reduced nutrition, dry skin, and reduced
turgor. Peripheral lymph nodes are not palpable. Lungs and heart are without pathological changes.
Pulse rate is 80 beats per minute, blood pressure - 110/70 mm Hg. The tongue is covered with white
plaque. The abdomen has a usual configuration, is involved in breathing. A palpation marks pain in
the right iliac area, where condensed and painful caecum and some small bowel loops are palpated.
Liver is along the costal arch. The spleen is not palpable
1. Crohn's disease, ileocolitis with damage to the terminal ileum, chronic

recurrent course, moderate to severe, complicated by perianal lesions
. 2.
The diagnosis is suspected on the basis of an anamnesis: a thickened iliac was detected during
surgery
intestine with loose swelling of the wall, an increase in the mesenteric lymph nodes,
unchanged vermiform
process during surgery and during histological examination; chronic diseases
that accompany diarrhea, fever in the patient, perianal fistula. Syndromes
severe malabsorption and maldigestion moderate
3. The patient is recommended a biochemical blood test with determination of electrolytes
and
trace elements (magnesium, iron, calcium) to assess the degree of maldigestion; fecal analysis
blood for antibodies ASCA and ANCA for differential diagnosis with CDD; Ultrasound of
organs
the abdominal cavity to detect hepatomegaly, splenomegaly, lymphadenopathy of the
abdominal cavity;
fibrocolonoscopy with biopsy to detect granulomas as well as massive lymphoid
infiltration of all layers of the intestinal wall - a type of pavers with fibrocolonoscopy;
feces for mycobacterium tuberculosis for differential diagnosis with tuberculosis
bowel damage; barium passage through the intestines (there is a narrowing of the distal
ileum and, possibly, a change in the wall of the cecum and ascending intestine,
characteristic of Crohn's disease, in which fibrosis of the wall develops with a violation
patency)
4. As anti-inflammatory therapy - corticosteroids: prednisone 150 or more mg iv
drip, then inside - 1 mg / kg of patient body weigh In the absence of contraindications and
availability
Opportunities - Anticytokine therapy is recommended as soon as possible:
In addition to anti-inflammatory therapy, pathogenetic therapy includes decontamination
intestines: parenteral metronidazole.
Correction of electrolyte disorders, treatment of malabsorption, maldigestion
Clinical task 17
Patient S., 46 years old, after the act of defecation notes unpleasant sensations, itching in the anal
canal, bleeding with a bright red blood, not mixed with feces. On objective examination during
tension below the Hilton line, in the projection of "7 hours" in the position on the back a tumor-like
formation is determined. It is oval, with superficial ulcerations and traces of hemorrhage.
1) Chronic hemorrhoids
2) Diagnostics
● Proctological examination (site examination, digital examination, anal mirrors)
● Sigmoidoscopy (after subsiding inflammatory phenomena)
● Fibrocolonoscopy, irrigography (Differential diagnosis of other diseases (in doubtful
cases))
● Complete blood count
● Urinalysis
● Blood test per group and Rh, HIV, RW
● Overview R-graph of the chest
● ECG, general practitioner consultation
3) Treatment:
conservative therapy
● diet (exclusion of spicy foods, alcohol)
● against hemorrhoids ointments ("Posterisan", "Relief", "Ultraproct", "Aurobin")
● laxatives (Senade et al.),
● anti-inflammatory
● thrombolytic therapy
● phlebotropic drugs (detralex, etc.)
● from 3-4 days - sedentary warm baths with KMnO.
surgery
● minimally invasive techniques (latex rings, sclerotherapy, electrotherapy, photocoagulation
and
etc.)
● hemorrhoidectomy (according to Milligan-Morgan, according to A.N. Red, modifications)
Clinical task 18
Patient Z., 18 years old, complains of intense, sharp pain in the perineum, which is increased by
tension, and the act of defecation, increased body T to 39.0, rigor. At inspection in a perianal area
hyperemia of skin to the right of an anus, hypostasis and swelling of fabrics is noted, at a palpation
sharp pain and fluctuation
1) Acute subcutaneous paraproctitis

2) Diagnostics:
● Proctological examination (site examination, digital examination)
general analyzes
● Urinalysis
3) Surgical treatment :
● Disclosure and drainage of the abscess to be performed under general anesthesia
●
Local therapy is carried out by daily washing of the formed cavities.
antiseptics, insert turund with water-soluble ointments
Clinical task 19
Patient V., 30 years old, complains of perineum fistula with purulent content during last year.
Examination of the perineum skin revealed a fistula with a slight purulent content and skin
maceration around it. By a palpation in hypodermic fatty tissue the solid cord is detected
1) Chronic paraproctitis. external fistula

2) Diagnostics:
• Proctological examination (site examination, digital examination)
• Sounding fistulous course
• Endoscopic examination
• Fistulography
• endorectal ultrasonography and MRI
3) Treatment:
surgical
• Excision or dissection of the fistula into the lumen of the rectum
• Excision of the fistula with ligature.
• Excision of the fistula with the elimination of the internal opening by reducing the mucus-
muscular
flap (operation Judd-Robles in the modification of V.M. Maslyak).
• Methods of treating fistulas with alloplastic materials (fibrin glue, collagen
"Stub", after surgical debridement of the fistula)
Clinical task 20
A 40-year-old patient has been suffering from chronic hemorrhoids for 6 years. Two days ago, after
alcohol drinking and spicy food, there were sharp pain in the anus, increased by coughing,
movements. On examination in the area of the anus for "7" hours in a supine position - enlarged,
bluish hemorrhoid, sharply painful by palpation.
4) Acute hemorrhoids. Hemorrhoidal Thrombosis

5) Diagnostics
Finger examination, anoscopy and rectoscopy through severe soreness do not
applied (it is possible to use anesthesia for diagnostic
procedures for differential diagnosis with a fissure, a tumor of the rectum and
etc.)
● Urinalysis
6) Treatment: In this case, conservative therapy is indicated.
● diet (exclusion of spicy foods, alcohol),
● laxatives (Senade et al.),
● anti-inflammatory
● thrombolytic therapy
● phlebotropic drugs (detralex, etc.)
● from 3-4 days - sedentary warm baths with KMnO.
In case of inefficiency - operation: opening of the thrombosed site, removal of thrombotic
mass
Submucous thrombectomy (dissection of the hemorrhoid, removal of thrombotic
mass)
Clinical task 21
Patient N., 62 years old, complains of a moderate pain in the perineum, mucous secretion from the
rectum. Finger rectal examination: in the lower ampullary part of the rectum revealed several
formations with a diameter from 0.5 to 1 cm, with a well-defined leg, which are displaced together
with the intestinal mucosa.
Polyps of the lower ampulla of the rectum

diagnostics:
● Proctological examination (site examination, digital examination, anal mirrors)
● Sigmoidoscopy
● Colonoscopy or CT colonography.
● Double-contrast irrigography (rare).
● Histological examination of pathological tissue that has been removed by the whole
complex,
makes it possible to determine the type of polyp (neoplastic [incl. Variety of adenoma and
degree
dysplasia], or non-tumor)
Surgical treatment:
● Polypectomy through a sigmoidoscopy or fibrocolonoscope with electrocoagulation of the
leg or
tumor base
● transanal neoplasm clipping
● Removal of tumors by colotomy or resection of the colon via an intraperitoneal approach
(by
signs of malignancy or inability to remove in another way)
Clinical task 22
Patient A., 42 years old, is suffering from constipation. Notes a sharp pain in the anus with irradiation
to the perineum at the time of defecation. There is a minor bleeding in the form of streaks on the
feces surface after defecation. At anoscopy: there is the longitudinal wound 1,3-1,5 cm in length in a
site of a back commissure with solid edges and the bottom which is covered by granulations.
1 - Diagnosis: Acute anal fissure

2. - Research: 1. review of the perianal region with easy dilution of the buttocks, anoscopy
with
the use of 2% lidocaine gel, in most cases, laboratory diagnostics do not require.
3. - Tactics and treatment: 1. Conservative treatment - The goal of therapy is to eliminate
constipation and
rupture of the vicious circle "hard feces - sore stools - increased constipation." Liquid feces
stool for
the patient is less painful. First-line drugs are drugs that provide
fecal volume, such as plant fiber supplements and stool softeners. When
the need for regular bowel movements is prescribed laxatives. For relax
emptying without trauma to the mucosa, you can prescribe emollient candles, as well as
mineral
oils, but they should not be abused. Useful sitz baths after emptying because
they significantly reduce pain, easing spasm. Second line therapy is local
applying 0.2% ointment of nitroglycerin to the internal sphincter 2-3 times a day. Some
doctors
prescribe this drug immediately, at the same time as the remedies. Nitroglycerin
ointment is prescribed to relax YOU and reduce pain, it also enhances the blood flow in the
mucus
anal canal. Unfortunately, the use of nitroglycerin ointment in many patients
accompanied by side effects, primarily pain and dizziness. Newest method
treatment of acute and chronic anal fissures is an injection of botulinum toxin
directly in YOU, which provides a "chemical sphincterotomy." The effect lasts up to 3
months until nerve endings regenerate. This period allows the healing of an acute crack. 2.
Surgical treatment - sphincter dilatation; Lateral internal sphincterotomy.
Clinical task 23
Patient K., 56 years old, complains of gas incontinence, rectal prolapse during defecation, which is
self-exercising. Objectively: when the patient strains the conelike part of rectum with a corrugated
surface moves out. Mucous membrane is without changes.
1. - Diagnosis: Complete prolapse of the rectum.

2. - Diagnosis and examination: 1. Anamnesis (As usual, patients first note
prolapse of the rectum only after bowel movement, it independently copes with
getting up. With the progression of the disease, loss occurs more often, especially with
tension, coughing, sneezing. In the future, precipitation is noted in everyday
activity and in the end, at rest, constantly.; Pain; Fecal Incontinence, 2. Examination -
The patient is asked to sit down, as in the toilet, and push, after this should happen
prolapse of the rectum. If it doesn’t occur, then a phosphoric enema is performed,
which provokes prolapse. 3. Additional methods - defecogram: the patient is administered
paste barium sulfate into the ampoule of the rectum and ask to empty under x-ray control.
in case of obvious prolapse of all layers of the rectal wall, the need to perform
video defecography no. Defectography allows in difficult cases to differentiate
mucosal prolapse from prolapse of all layers of the rectal wall, and also to identify
internal prolapse (invocation). Before surgery, it is necessary
a detailed examination of the colon by performing irrigoscopy or colonoscopy.
- Tactics of treatment: there is no drug treatment for prolapse of the rectum. However, with
the internal prolapse of treatment, as usual, begins with the appointment of anti-inflammatory
drugs (underwear
feces and volume-forming), suppositories and enemas. Surgical treatment includes two main
groups
operations - abdominal and perineal interventions. The choice of intervention is dictated
first of all, the age of the patient and the presence of concomitant pathology, as well as the
presence or
lack of constipation.: Anterior bowel resection belongs to abdominal interventions . In
during the operation mobilize the rectum to the level of the lateral connection and resect the
sigmoid
gut with an anastomosis between the left half of the colon and the upper part of the rectum
guts. The second type of abdominal surgery is rectopexy - fixation of the rectum to
presacral fascia using sutures or non-smeared mesh. Perform also
combined intervention - resection rectopexy (Frickman-Goldberg operation),
which consists in combining anterior resection with rectopexy. It’s a good choice in case
if patients have severe constipation. Perineal surgery belongs to anal encirclement
- implantation of a metal or plastic ring under the skin around the anus, which prevents
prolapse of the rectum. The second option for perineal interventions is surgery.
Delorme (Delorme): the intestinal mucosa, which fell out circularly dissected at the dentate
line, and the muscles
corrugations with seams and pull up. The edges of the dissected mucosa are sutured. This
the operation is used mainly for small prolapse. And finally, the third type
Operations is perineal rectosigmoidectomy (Altemeier surgery). Rectum
cross at a distance of 1-2 cm from the gear line. Then bring the gut down, cross and
bandage the mesentery until the intestine can no longer be pulled down. Then they cross her
screw back into the anal canal and impose a manual or hardware anastomosis
Clinical task 24
A 18-year-old patient complains of pain in the buttocks. On examination, the skin of the
sacrococcygeal zone is hyperemic, swollen, sharply painful on palpation, there is a hole in the center
of the hyperemia, when pressing on the surrounding tissues from which the product pus is released.
At audit of a fistula the button-shaped probe does not get into a rectum
Diagnosis: suppuration of the epithelial coccygeal passage (pilonidal cyst)

diagnostics:
Clinical blood test - a shift of the leukocyte formula to the left, neutrophilic leukocytosis,
increase in ESR.
Urinalysis: leukocyturia, proteinuria (as signs of an inflammatory process)
A blood test to determine the group according to the AB0 system and Rh factor.
HIV test.
Wasserman reaction.
Blood chemistry
Blood glucose test
Finger examination.
Anoscopy
Sigmoidoscopy.
Contrast fistulography (iodolipol, urographin, hypak) with radiographs in two projections.
Sensing fistulas with a metal probe under the control of a finger or the introduction of a 1%
solution
methylene blue under the control of a cotton swab in the anal canal.
X-ray of the sacrum and tailbone
treatment:
Surgical - excision of the coccygeal passage, removal of manure, revision of the wound,
rehabilitation, suturing,
toilet wounds daily with suture treatment with 0.5% chlorhexedine solution.
antibiotic prophylaxis
Rp; Ceftriaxoni 1.0
DtdN 15
S. Dissolve the contents of 1 vial in 3 ml of water for injection or in 2 ml of a 2% solution of
novocaine.
Enter IM 2 times a day for 5-7 days.
Rp: Sol. Diclofenaci Natrii 2.5% - 3.0
DtdN 5 in amp.
S. Intramuscularly administered in 3 ml once a day.
Rp: Tab. Ciprofloxacini 0.5
DtdN 15
S. Take 1 tablet by mouth every 12:00 for 5-7 days
Clinical task 25
A patient 27 years old (height 179 cm, weight 71 kg) complains of sharp ("knife - like") pain in the
epigastrium, which started 3 hours ago, quickly spread throughout the abdomen, dry mouth, thirst,
nausea. At the beginning of the pain he noticed irradiation in the right shoulder area. The condition is
severe. Forced position of the patient - lies on the right side with the hips brought to the abdomen,
the pain increases sharply with movement. Blood pressure is 90/60 mm Hg. Pulse rate is 112 beats
per 1 min. The abdominal wall is involved, does not participate in the act of breathing. By palpation:
muscle tension of the anterior abdominal wall. By percussion: absence of hepatic dullness.
Diagnosis: Perforated gastric ulcer / duodenum. Pneumoperitoneum?

diagnostics:
increase in ESR.
General urine analysis
HIV test.
Wasserman reaction.
Blood chemistry
Blood glucose test
Palpation and percussion of the anterior abdominal wall - Mondor Triad (ulcerative history,
dagger pain in the epigastrium, “prescale” abdomen), Eleker's symptom (irradiation of pain in
right or left shoulder, supraclavicular area, scapula), Spizharsky's symptom (decrease or
disappearance of hepatic dullness)
Radiography of OBP - signs of air in subphrenic spaces (Jobert symptom)
FEGDS (perforated stomach ulcer or duodenum)
Pneumogastrography
Laparocentesis with a Neymark breakdown (abdominal puncture in the midline of the
abdomen 2-3 cm higher
navel at an angle of 40 *, aspiration of exudate, sample with the addition of 4-5 drops of 10%
iodine solution -
brown color indicates the presence of gastric contents)
laparoscopy
treatment:
Prompt!
Preparation for surgery 1.5 - 2 hours.
Vagosympathetic or perinephric block.
Neuroleptanalgesia (droperidol, fentanyl)
Polyglukin 200-400ml + hydrocortisone - mg
Correction of hypovolemia, water-salt and acid-base balance (10% glucose 500.0, solution
Ringer-Locke - 500.0, aminopeptide - 500.0)
decompression of the stomach
operation
Access - upper median laparotomy. Revision of OBP. Suturing perforation or tamponade
omentum on the leg (Operation Oppel 1896), or gastrectomy.
Stem or selective proximal vagotomy.
Sanitation of the abdominal cavity and drainage with silicone tubes (subphrenic,
subhepatic space, pelvic cavity, left iliac region) 4-6 days after
operations. Nasogastric decompression of the small intestine and slug.
Antibiotic prophylaxis - chloramphenicol 0.5 2 r / d 7-14 days / m
Biseptol 9.6% - 5 ml 1 r / day for 14 days / m.
Federov-Fowler position (raised head end of bed
Clinical task 26
A 26-year-old patient was brought to the surgical department with complaints of weakness,
dizziness, moderate pain in the epigastric area, black liquid stool. He felt bad 8 hours ago. At the age
of 22 he underwent surgery for duodenal ulcer perforation, suturing of the ulcer were performed.
After surgery he got three peptic ulcer attacks, was treated conservatively. The skin is pale. Pulse rate
is 110 beats per 1 min. Blood pressure is 90/60 mm Hg. Respiration rate is 24 per minute. By
palpation: the abdominal wall is soft, painfulness in the epigastric and right hypochondria regions. By
percussion: absence of hepatic dullness.
Diagnosis: duodenal ulcer in the acute stage. Bleeding ulcer of the
duodenum. Gastrointestinal
bleeding. Pneumoperitoneum?
diagnostics:
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Clinical blood test - a decrease in hemoglobin, red blood cell count, hematocrit,
posthemorrhagic neutrophilic leukocytosis, anisocytosis, poikilocytosis, polychromasia,
decrease in the amount of total protein, determining the amount of blood loss due to
hematocrit,
hemoglobin and specific gravity of blood.
General urine analysis
HIV test.
Wasserman reaction.
Blood chemistry
Coagulogram.
Fecal analysis - ground, traces of blood, red blood cells.
Blood glucose test
FEGDS: visualization of a bleeding ulcer, signs of stable (lack of blood in the stomach and
duodenum,
the ulcer is covered with fibrin of white or dirty gray color, the lumen protruding above the
crater
ulcers vessels closed by a white blood clot) and unstable (the presence of light blood, blood
clots in
stomach, loose bundle of blood dark brown over the ulcer, pulsation of the vessel) hemostasis.
Contrast fluoroscopy / radiography: a symptom of "repulsion" of the barium mixture.
(Not currently used).
Selective angiography of the branches of the abdominal aorta: a sign of continued bleeding is
getting contrast in the lumen of the digestive tract.
treatment:
Conservative treatment (1 severity of blood loss)
Strict bed rest
Catheterization of two veins
Red blood cell transfusion, plasma.
The introduction of hemostatic drugs - fibrinogen, aminocaproic acid, cryoprecipitate,
calcium chloride, vicasol.
Administration of protease inhibitors (trasilol, contracal)
Inhibition of gastric secretion (atropine sulfate, N-2 receptor blockers - famotidine,
ranitidine)
Inhibition of fibrinolytic activity (aminocaproic acid, oral)
Guided hypotension (arfonad, pentamine)
restoration of bcc
Local hypothermia (gastric lavage with cold water)
Diet Meilengracht (sour cream, raw chilled eggs)
Electrocoagulation, photocoagulation, the use of glue KL-3 with FEGDS
Surgical treatment (indications - profuse bleeding, recurrent bleeding in
history of recurrence of bleeding during treatment or failure of conservative treatment,
localization of ulcers in the area of increased blood supply, unfavorable endoscopic picture
(deep ulcer, callous ulcer thrombosed by a vessel))
Preparing the patient for 1.5-2 hours.
endotracheal anesthesia
Access - upper median laparotomy.
Longitudinal gastrotomy and revision of the stomach and duodenum (in the absence of data,
sho indicate
ulcer)
Firmware, dressings, diathermocoagulation of bleeding vessels or related areas
mucous membrane, overlaying an 8-shaped suture on an ulcer.
Palliative surgery in extremely severe patients (piercing of bleeding vessels with
sides of the mucous membrane, wedge-shaped excision of an ulcer, piercing the wall of the
stomach through and through
the perimeter of the ulcer, followed by the imposition of serous-muscle sutures, suturing a
bleeding ulcer
stomach and duodenum).
With localization of an ulcer on the posterior wall of the duodenum, duodenotomy, visual
arrest of bleeding
(vascular stitching, diathermocoagulation, filling with medical glue), vagotomy and
pyloroclasty.
For elderly patients - excision of an ulcer with pyloroplasty and vagotomy or firmware
vessels through the gastrotomy opening in combination with pyloroplasty and stem vagotomy.
Enteral nutrition from 2-3 days after surgery
Clinical task 27
A 44-year-old patient was brought to the admission department with complaints of abdominal pain,
dry mouth, and general weakness. From the anamnesis it is known that 2 days ago he felt a sharp "
knife - like " pain in the epigastrium, which gradually became diffuse. He has been suffering from
peptic ulcer disease about last 15 years. Pulse rate is 104 beats / min. Blood pressure is 100/70 mm
Hg. The abdomen is swollen, moderately tensed; painfulness in all parts is present. Peristalsis is not
listened.
1) Diagnosis: Peptic ulcer complicated by perforation.

2) Diagnosis: Positive symptoms of Dielafua (dagger abdominal pain), Mondor triad
(dagger abdominal pain, abdominal-like board, ulcerative history), Krasnobaev-Crewell
(belly-like board).
Laboratory: marked leukocytosis with a shift of the formula to the left, signs of
hemoconcentration
(increase in hemoglobin and hematocrit), increase in ESR, increase in creatinine,
urea.
With a panoramic fluoroscopy (-graphy) of the abdominal cavity, free gas under the dome is
determined
diaphragms - cm. Levy-Dorn; if the clinic and radiological data do not match -
Neymark test is carried out.
In doubtful cases when X-ray research methods do not allow to confirm
diagnosis, urgent fibrogastroduodenoscopy is necessary. The method allows to identify
localization
perforation, the presence of multiple ulcers, reflux of duodenal and gastric contents.
In the most severe cases for diagnosis, laparocentesis or laparoscopy is used.
3) Treatment: Preoperative preparation is an essential component of treatment
programs. With perforation of gastroduodenal ulcers, therapeutic measures of preoperative
training should have the following focus: elimination of pain, recovery
BCC, improved microcirculation, prevention of infectious complications, symptomatic
therapy of concomitant diseases. The volume of intravenous infusion therapy is 15-20
ml per kilogram of patient weight. To compensate for these losses and correct hemodynamic
For disorders, an isotonic solution (0.9%) of sodium chloride or Ringer-Locke solution is
used.
Patients in a state of shock to quickly correct blood pressure, as well as to eliminate clinical
signs of microcirculation disturbance, in the initial phase of infusion therapy is used
administration of a hypertonic (5-7.5%) sodium chloride solution in combination with a
dextran solution
(reopoliglyukin) in the ratio 1: 1 in about "volume of 2 ml per kilogram of patient weight.
Antibiotic prophylaxis of infectious complications includes the use of drugs
broad spectrum of action
Depending on the volume, all operations for perforated ulcers can be divided into three
groups:
palliative conditionally radical; radical.
Palliative operations include suturing and all types of plastic perforation closure
holes. The main goal of palliative surgery is to save the patient’s life by
eliminate the source of peritonitis.
Conditionally radical operations include excision of a stomach ulcer or duodenum followed
by
plastic defect.
The scope of radical operations includes the removal of ulcerative substrate and the
elimination of pathogenetic
ulceration factors. These include resection of the stomach or vagotomy, supplemented
excision of an ulcer with pyloric or duodenoplasty.
The choice of the method of operation is determined by the age of the patient, the localization
of the ulcer, the duration
ulcerative history, expressiveness of morphological changes on the part of the ulcer and
surrounding
tissues, features of the acid-forming function of the stomach, as well as the severity of the
patient’s condition,
which is due to the presence of progressive peritonitis, hemodynamic disorders and
concomitant pathology.
Clinical task 28
A 38-year-old patient complains of belt - like, constant, intense, pain in the epigastric region of the
abdomen with irradiation to the left shoulder zone, nausea, frequent vomiting, which does not bring
relief; sharp general weakness. History: acute onset of the disease started 30 hours ago after alcohol
drinking and fried fatty meats. The objective condition is serious. Body T is 37.7 ̊C, pulse rate 102 per
1 min, blood pressure 100/60 mm Hg. Pale skin with cyanotic spots on the trunk, difficulty breathing
is observed. The abdomen is swollen and painful on palpation in the projection of the pancreas.
Peristalsis is sharply weakened.
Diagnosis: Acute pancreatitis, moderate, uncomplicated.

diagnostics:
lymphopenia and increased ESR ..
General analysis of urine (A small amount of protein, and in the sediment - red blood cells,
individual hyaline
cylinders as a manifestation of focal jade)
HIV test.
Wasserman reaction.
Biochemical blood test (hypocalcemia manifests itself from the 2-3rd day of the disease, the
maximum
a decrease in calcium is on the 6th day, and on the 12-13th day its content reaches normal.
Hypercholesterolemia and Hyperphosphatemia)
Blood glucose test
Palpation and percussion of the anterior abdominal wall - significant palpation is detected
soreness (Mayo-Robson symptom) in the left rib-vertebral corner, marble spots in the form
individual sites on the anterior abdominal wall (Halstead symptom), lateral parts of the
abdomen
(Gray - Turner symptom), around the navel (Cullen symptom), the appearance of purple spots
on the face and
trunk (symptom of Mondor). Due to damage to peripheral vessels in acute
pancreatitis and a violation of the permeability of their walls, ecchymoses sometimes occur
around the navel
(symptom of Grunwald). The resistance of the abdominal wall in the form of a transverse
strip, which
placed 6-7 cm above the navel and corresponds to the topographic position of the pancreas
(Kerth symptom). There is no pulsation of the abdominal aorta in the epigastric region due to
edema
glands (a symptom of the Resurrection).
Determination of blood amylase (already after 3-4 g from the onset of the disease is elevated
(norm 16-
30 mg / l))
Determination of lipase in the blood - an increase in the level (norm 40-175 g / l).
Ultrasound examination allows to establish etiological factors (cholecyst - and
choledocholithiasis), the severity of morphological changes in the pancreas and the course of
the disease,
concomitant complications of the disease. Accuracy of diagnosis of cholecystitis and impaired
outflow
bile ultrasound reaches 92-98%. Signs of pancreatic edema
The gland is an increase in its volume and a decrease in the degree of reflection of the signal.
With pancreatic necrosis, unsharply delimited areas of reduced
echogenicity or complete absence of an echo signal. The spread of necrosis beyond the
pancreas
glands, as well as abscesses, can be visualized by ultrasound. Computed tomography gives
the ability to characterize in more detail changes in the pancreas and surrounding
organs.
With a panoramic radiography of the abdominal organs, you can detect the presence of a
dense shadow,
located at level T
12
-L
2
unfolded "horseshoe" of the duodenum, pneumatization
and expansion of the transverse colon (Gobier symptom), high standing level of the
diaphragm with
the presence of fluid in the pleural cavity
Laparoscopy and laparocentesis are often used for a dubious diagnosis of exudate collection.
abdominal cavity for biochemical or bacteriological examination to establish
drainage for treatment
Retrograde endoscopic pancreatocholangiography is used in cases of mechanical
jaundice and suspected choledocholithiasis
treatment:
The treatment of acute pancreatitis must be started at the prehospital stage, using: 1)
cold on the epigastric region (ice bladder, chlorethyl irrigation) 2) antispasmodics (1-2 ml
2% papaverine solution, 2 ml of 2% no-shpa solution, 2 ml of 12% aminophylline solution, 5
ml of baralgin,
nitroglycerin under the tongue) 3) anticholinergics (1 ml of a 0.1% solution of atropine, 1 ml
of a 0.1% solution
scopolamine) 4) antihistamines (2 ml of a 1% solution of diphenhydramine, 2 ml of a 2%
solution
pipolfen) 5) sounding of the stomach, taking antacids (almagel, phosphalugel) 6)
kinin inhibitors (20 ml of a 4% solution of amidopyrine in / u, 2 ml of a 50% solution of
analgin in / in).
Infusion therapy - the volume and composition is determined by the specific clinical situation.
The solutions are administered in the following proportions: 1000 - 1500 ml of 0.9% No. SI
or Ringer's solution, 400 ml of 4%
NaHCO3 solution, solutions containing sorbitol or xylitol: sorbylact, rheosorbylact 6-8 ml per
1
kg, Xylate 10-15 ml per 1 kg of patient weight (they must be administered before the
introduction of solutions
glucose for the purpose of its optimal assimilation), or 15% mannitol solution at the rate of
1.0 - 1.5 g per 1 kg
patient weight, 20 ml of 2.4% solution of aminophylline, 60 ml of 3% KC1 solution, 50 ml of
10% NaCl solution,
200 ml of 1% CaC12 solution per
1000 ml of 5% glucose solution, 1000-1500 ml of protein preparations (for every 3% Ht,
which exceeds
45, 300 ml of protein district is introduced - native and freshly frozen plasma, albumin,
hydrolysates).
It is necessary to keep the CVP at the level of 0.5-1.17 kPa (60-120 mm. Water. Art.),
Diuresis - at the level of 40-
60 ml / h, AO - 11.7 kPa (88 mm Hg), with a significant decrease in blood pressure,
norepinephrine is prescribed,
ephedrine, mesatone, after which pentamine is used to relieve spasm of peripheral vessels,
arfonad.
Blockade of secretory activity of software:
a) nasogastric suction, N, is used to reduce the acidity of slag juice
2
blockers (ranitidine, famotidine), atropine; b) to interrupt the synthesis of enzymes - dalargin
2
ml 2 times a day, 5-fluorouracil (fluorofur) 10 mg / kg 1-2 times a day for 3-4 days. The best
a tool that helps suppress the secretion of software is sandostatin, which is prescribed at 0.1
mg 2-3 times a day, or stylamine; c) protease inhibitors: contracal 80 - 120 thousand units
intravenously per day
within 3-5 days (gordox, trasylol - in equivalent doses), blockade of cytokines (pentoxifylline
- 20 ml / day for 5-7 days) g) to reduce secretory pressure in the ducts of PO -
papillosphincterotomy, wirsungotomy, single or prolonged nasopancreatic
drainage with the introduction of fluorouracil in the strait of PO.
Prevention of purulent infection (translocation of intestinal microflora):
a) enterosorption and Intraintestinal lavage;
b) correction of metabolic disorders with subsequent restoration of barrier function
intestines (glutamine, arginine, antioxidants)
c) selective intestinal decontamination (polymyxin, norfloxacin, amphotericin B);
d) early through probe supply;
e) antibiotic therapy.
- carbapenems (tienam of 500-1000 mg 3-4 times a day intravenously drip or meronem 500-
1000
mg 3 times a day intravenously)
- fluoroquinolones II - IV generation (ciprofloxacin - 400 mg 2 times a day, ofloxacin (tarid)
400
- 800 mg 2 times a day intravenously drip, pefloxacin (abactal) 400 mg 2 times a day
intravenously
drip, levofloxacin (Leflocin) 500 - 1000 mg 1-2 times a day in / drip, gatifloxacin
400 mg 1-2 times a day.
- cephalosporins III - IV generations; ceftriaxone (LENDACINE, Oframax) - 1 - 4 g 1 - 2
times per
day, cefoperazone (cefobid) - 1 - 4 g 2 times a day, cefotaxime (claforan) 1 - 3 g 4 times a
day,
cefepime (Maksipim) 1 0 - 2.0 g 4 times a day.
Surgery:
testimony
1 Progression of peritonitis.
2 Deterioration of the patient's condition, despite intensive care: lowering blood pressure,
diuresis of less than 1000 ml / day, progression of obstructive jaundice, conservation
obstruction of the duodenum or colon within 3 days of conservative therapy,
increased intensity of pain, vomiting, body temperature, hectic nature of the temperature,
treatment inefficiency in the presence of gallstone disease, cysts of PO, arosive
bleeding, perforation of the abdominal organ.
3 Progression of biliary pancreatitis in the presence of destructive calculous
cholecystitis, choledocholithiasis, could not be eliminated using endoscopic
papillosphincterotomy.
4 Assumption of another acute abdominal disease.
5 Increase in infiltrate of software or parapanreatic fiber with inefficiency
minimally invasive percutaneous interventions (puncture and drainage under the supervision
of ultrasound and
CT).
Surgical Techniques
1 Endoscopic single or prolonged nasopancreatic drainage or
nasopancreatic drainage with papillovirusungotomy in the presence of restrained stone,
polyp, stenosis of the large papilla of the duodenum or ducts of the PO, navicle papillary
diverticulum.
2 Laparoscopic abdominal lavage is used in patients with pancreatogenic peritoneal
nit when detecting a cloudy effusion and the absence of necrosis
Laparotomy without intervention on the pancreas is used for edematous GP
3 software abdomination. Cut the peritoneum along the upper edge of the software so that the
enzymes secreted do not
fell into retroperitoneal prostere and free outflow was carried out. N.N. Malinovsky
suggested, in addition, to hem the dissected gastro-colonic ligament to keep the secret
freely stood out without getting into the abdominal cavity. The operation is performed mainly
when
small focal pancreatic necrosis in patients who underwent laparotomy under the assumption
another surgical disease.
4 omentopancreatopexy. V.S. Saveliev proposed to wrap the mobilized software with a gland
at
focal pancreatic necrosis, including large focal. Due to the high risk of secondary
Software infection, methods for its abdomination and omenopancreatopathy are rarely used.
Pancreatonecrectomy. Economical necrotic tissue cutting by I.Rives suggested
(1974). The surgeon removes necrotic areas of software by hand, this operation is usually
performed
in the period of 7-14 days from the onset of the disease. Veger proposed to remove dead
sections of software, cavity
drain with flowing drains; sew up the delimited cavity. The cavity is washed
daily type of lavage.
Clinical task 29
A 55-year-old female suffers from gallstone disease. After alcohol abuse and fried food, there was
the belt - like pain in the epigastric region with irradiation in the back, nausea, repeated vomiting,
which did not bring relief. On examination: the condition is extremely severe, shallow breathing.
Yellow-cyanotic spots are on the skin around the navel. The abdomen is swollen and painful on
palpation in the projection of the pancreas. Peristalsis is sharply weakened.
Diagnosis: Acute Biliary Pancreatitis

1. Laboratory research
1) changes characteristic of GP - an increase in the activity of pancreatic enzymes
(typically> 3 × BMN):
a) lipases in the blood (the greatest sensitivity and specificity in the diagnosis of GP) amylase
blood and urine - in the blood after 48-72 hours the activity often decreases to normal, despite
continuation of the disease; increased activity of total amylase in the urine and activity remain
pancreatic enzyme in the blood
2) disorders that reflect the severity of the disease or the development of complications -
leukocytosis
with a shift to the left, an increased concentration of CRP (correlates well with the severity of
GP, especially in
the first 48-72 hours), the level of procalcitonin (PCT; correlates well with the severity of GP,
risk
the development of organ failure and infection of the PCh necrosis), elevated levels
serum urea (may indicate inadequate infusion therapy at the initial
stage of disease or impaired renal function and is an independent risk factor for death),
biochemical indicators of liver damage (hyperbilirubinemia, increased ALT activity,
AST, AP, GGT - indicate a biliary etiology of GP), polyglobulia (due to dehydration
[vomiting] and exudate or anemia (due to bleeding), hypoxemia, hyperglycemia,
hypertriglyceridemia, hypocalcemia.
2. Visualization methods of examination: ultrasound of the abdominal organs - examination
the first choice, but ultrasound often fails to visualize the pancreas (intestinal
gas, obesity); with GP: an increase in the pancreas, the fuzziness of its contours, decreased
and
heterogeneous echogenicity of the parenchyma; gallstone disease and GP complications can
be detected
(e.g. pseudocysts and infected fluid formations). Ultrasound with intravenous contrast
amplification allows visualization of pancreatic parenchyma necrosis.
CT with the introduction of contrast: makes it possible to assess the prevalence of pancreatic
necrosis -
tomographic indicator of severity of GP and necrosis of adipose and connective tissue around
pancreas. Do not routinely administer to patients with an obvious diagnosis.
the disease is smooth, and there are no complications. Perform a CT scan if the patient’s
condition is not
improves within 48-72 hours (eg., contains pain, fever, nausea, and oral
nutrition is impossible) to identify local complications such as necrosis
pancreas. An optimal estimate of the prevalence of necrosis is given by CT performed on
5th 7th day of the disease. The examination is performed immediately if the patient is
suspected of having
GP is in critical condition or requires urgent surgical intervention.
Assign the next examination in case of worsening clinical condition, increase
organ failure, symptoms of sepsis.
In case of contraindications to CT, as well as with the aim of differentiating liquid
formations appoint an MRI.
Chest WG: basal lung atelectasis, pleural exudate (especially
left-handed), ARDS.
WG abdominal examination: fluid levels or swollen loops can be detected
intestines
Endoscopic retrograde cholangiopancreatography (ERCP) - in severe
biliary GP, if performed urgently with sphincterotomy, becomes
treatment procedure → below.
Magnetic cholangiopancreatography (MRCP): performed in doubtful cases in acute
phase of the disease, mainly for the purpose of diagnosing cholelithiasis and evaluating the
pancreatic duct
in the presence of fluid / cyst collectors and fistulas in the late stage of the disease.
Endoscopic Ultrasonography (EUS): Auxiliary in determining etiological
the cause in people after suffering a GP or idiopathic recurrent pancreatitis and
late stage to identify fluid formations.
In the acute phase, first of all, intense intravenous flooding, elimination of pain and
diet therapy (after an initial abstinence from food). Other measures depend on the severity of
the disease and
the presence of complications.
conservative treatment
1. Initial therapy
1) during the first 12-24 hours to all patients without concomitant cardio-
vascular disease or kidney disease begin intensive in /
to rehydration → infusion of isotonic electrolyte solution
(eg. Ringer's lactate; preference is given to balanced
solutions → Sec. 24.22 ) 250-350 ml / h, under the supervision of clinical and
biochemical hemodynamic indicators in order to obtain: diuresis>
0.5-1 ml / kg / h, average blood pressure (SBP) 65-85 mm RT. c, heart rate
contractions <120 / min; urea nitrogen concentration (BUN) <20 mg / dl
(the highest is a decrease of ≥5 mg / dl during the first 24 hours), Ht 35-44%. Often
assess the need for rehydration in the first 6 hours of hospitalization and in
over the next 24-48 hours. In patients with severe hypovolemia
(hypotension, tachycardia) faster may be necessary
rehydration (bolus).
2) it is necessary to immediately correct possible electrolyte disturbances, especially
hypokalemia;
3) with hematocrit <25% → EM transfusion, until hematocrit 30-
35%;
4) with hyperglycemia> 13.9 mmol / l (250 mg / dl) → insulin therapy.
2. Elimination of pain: use metamizole iv once 1.0 g in case of more intense pain
opioid analgesic, e.g. sc or tramadol in / in 50 mg every 6-8 hours;iv buprenorphine 0.2-0.6
mg every 6 hours or meperidine iv 50 mg every 6-8 hours. Recommended method, despite
good analgesic effect and improvement of visceral blood circulation, is
long-term epidural blockade of the Th4-L1 segment with bupivacaine (10 ml 0.25%
solution, followed by infusion of 5 ml / h).
3. Therapeutic nutrition: with a mild form, it is not recommended if there are no signs of
malnutrition; after
the disappearance of pain, the patient can eat foods low in fat. At an early
stage, start oral nutrition (in the first 24 hours from the onset of the disease; possible causes of
delay:
abdominal pain, vomiting or obstruction), and in case of intolerance, start
enteral nutrition. In severe GP - within 24-48 hours it is necessary to start enteral nutrition
(if possible), if necessary, supplement it with parenteral
nutrition.
1) Fully enteral nutrition - through nasoenterial or, if necessary,
nasogastric tube use a mixture of protein hydrolysates of relatively low osmolarity
(300-390 mOsm / l) containing medium triglycerides (MCT) and immunoactive substances
(e.g. glutamine, ω-3 fatty acids) continuous infusion (within 24 hours, or 4 hours
night break), at the beginning at a speed of 10-20 ml / h gradually (2-4 days) increasing the
dose to 500-
2000 ml / day (maximum speed 100 ml / h). Complications: rarely occur and is not
dangerous (displacement or blockage of the probe and diarrhea, nausea and bloating resulting
from
too fast infusion of the food mixture).
2) Fully parenteral nutrition - only applies if nutrition through the digestive tract
cannot be applied; start after 48-72 hours, after stabilization of the hemodynamic state
the patient. It is necessary to monitor and equalize metabolic disorders (hypo- and
hyperglycemia, hypocalcemia, hypo- and hyperkalemia, hypophosphatemia, hypomagnesemia
and
violation of acid-base balance. Stop immediately as soon as it becomes
possible nutrition through the digestive tract.
4. Antibiotic therapy: do not use routine antibiotic prophylaxis in
patients with severe GP, as well as antibiotics in patients with
aseptic pancreatic necrosis in order to prevent it
infection. Antibiotics indicated for treatment of infection
pancreatic necrosis (→ Complications), as well as infections outside the pancreas
gland-cholangitis, catheter-associated infections, bacteremia,
infection of the urinary system, pneumonia. Do not use routine
antifungal drugs in combination with antibiotic therapy.
invasive treatment
1. ERCP with sphincterotomy: indicated for the first 24 hours in patients with concomitant
acute
obstructive cholangitis; not required in most patients with biliary GP without laboratory
or clinical symptoms of ongoing bile duct obstruction. Sick without
cholangitis and / or jaundice, in which there is a significant suspicion of choledocholithiasis,
with
in order to confirm it, carry out an MRCP rather than a diagnostic ERCP.
2. Cholecystectomy: if there are no contraindications, patients with mild biliary GP before
discharge
from the hospital, a cholecystectomy is necessary. In case of severe biliary GP
cholecystectomy is performed after the cessation of the active inflammatory process and
resorption
or stabilization of fluid tanks.
3. Removal of necrosis: infection of pancreatic necrosis is an indication for
invasive treatment to remove infected tissue. Advantage first
provided by percutaneous and / or endoscopic drainage, not opened
necrectomy. Surgical treatment can be entertained in case of severe GP with aseptic necrosis
covering> 50% of the pancreas and concomitant multiple organ syndrome
failure if clinical improvement does not occur within 4 weeks (impressions are
controversial)
Clinical task 30
A 55-year-old female was admitted to the surgical department with complaints of belt - like pain in
the epigastric region, frequent vomiting, which did not bring relief, delayed gas discharge. She was ill
during lust four days and did not call medical care. The skin and visible mucous membranes are pale;
the lips are cyanotic. Pulse is rhythmic, weak, rate is 140 beats per min. BP is 100/50 mm Hg. Body
temperature is 37.6ºC. Breathing is frequent. The tongue is dry. The abdomen is moderately swollen,
painful on palpation in the epigastrium with local muscle tension. Blumberg sine is negative.
Clinical task 31
A 68-year-old patient is treated in the surgical department for acute destructive pancreatitis. On the
10th day the condition worsened. Complaints of stabbing pain in the stomach, difficulty breathing.
Body temperature is 37.8ºC. A painful elastic infiltrate is palpated in the epigastric region. Symptoms
of peritoneal irritation are negative.
1) Diagnosis: Acute destructive pancreatitis, abscess (possibly pseudocyst) of the pancreas

glands.
2) diagnostics . Blood leukocytosis (up to 25 × 10
9
/ l sign of software necrosis) + At the same time
lymphopenia and an increase in ESR, the amount of hemoglobin and hematocrit increases.
Hypocalcemia, hypoproteinemia, hyperglobulinemia, hypoprothrombinemia,
hypofibrinogenemia.
In the urine, a small amount of protein, and in the sediment - red blood cells, hyaline
cylinders.
leukocyturia.
The amylase content in the blood is increased after 3-4 hours (the norm is 16-30 mg / l) (with
necrosis it can be
normal or low). Sub. lipases in the blood (normal 40-175 g / l).
increase in bilirubin level due to impaired bile outflow (norm 8.6 - 20.5 μmol / l).
Instrumental. Ultrasound - (cholecyst - and choledocholithiasis), the severity of
morphological changes,
concomitant complications, impaired outflow of bile. Signs of swelling of the software is an
increase in it
volume and reduce the degree of reflection of the signal. With necrosis, unsharply delimited
areas
reduced echogenicity or complete absence of an echo signal. The spread of necrosis beyond
PO, as well as abscesses.
Computed tomography - changes in the pancreas and surrounding organs.
survey radiography OBP - the presence of a dense shadow, placed at level T
12
-L
2
,
unfolded "horseshoe" of the duodenum, pneumatization and expansion of the transverse
colon (Gobier symptom), high standing level of the diaphragm with the presence of fluid in
pleural cavity.
Laparoscopy and laparocentesis - in case of doubtful diagnosis, abdominal exudate collection
for biochemical or bacteriological studies to establish drainage for treatment.
Retrograde endoscopic pancreatocholangiography - in cases of obstructive jaundice and
suspected choledocholithiasis.
3) positive symptoms:
* Kerte - resistance of the abdominal wall in the form of a transverse strip, which is located at
6-7
cm above the navel and corresponds to the topographic position of the pancreas.
* Voskresensky - there is no pulsation of the abdominal aorta in the epigastric region due to
edema of the gland.
* Mayo-Robson - detection of palpation of a painful point in the left rib-vertebral corner.
not permanent.
* Grunwald - As a result of damage to peripheral vessels in acute pancreatitis and
violation of the permeability of their walls, ecchymoses occur around the navel.
* Mondora - the appearance of purple spots on the face and body.
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* Olsted cyanotic spots on the anterior abdominal wall
* Gray-Turner - The sides of the abdomen around the navel
4) Treatment of acute pancreatitis
Conservative treatment
at the prehospital stage:
1) cold on the epigastric region (ice pack)
2) antispasmodics (1-2 ml of a 2% solution of papaverine, 2 ml of a 12% solution of
aminophylline, 5 ml of baralgin)
3) anticholinergics (1 ml of a 0.1% solution of atropine, 1 ml of a 0.1% solution of
scopolamine)
4) antihistamines (2 ml of 1% diphenhydramine solution, 2 ml of 2% pipolfen solution)
5) sounding of the stomach, taking antacids (almagel, phosphalugel)
6) kinin inhibitors (20 ml of a 4% solution of amidopyrine in / u, 2 ml of a 50% solution of
analgin in / in).
in a hospital are:
1. Chills: a) analgesics, mainly non-narcotic: analgin, baralgin, ketalong,
novocaine blockade (perinephral), epidural anesthesia;
c) antispasmodics (no-shpa, papaverine) 3-4 times a day.
2. Correction of central hemodynamic disorders and peripheral circulation
- blood cells (with a mild degree - up to 2-4 l heavy - 6-10 l); the introduction of plasma and
albumin.
3. Infusion therapy: 1000 - 1500 ml of 0.9% No. SI or Ringer's solution, 400 ml of 4%
solution
NaHCO3, sorbylact, rheosorbylact 6-8 ml per 1 kg, Xylate 10-15 ml per 1 kg of patient
weight
4. To improve the microcirculation of the districts of 6% -10% hydroxyethyl starch (HES) -
Stabizol,
Reformed, Gekodes, rheosorbylact.
5. For the correction of anemia, hypoxia, transfusion of small doses of fresh single-group
erythrocyte
mass or washed red blood cells.
6. With a significant decrease in blood pressure - norepinephrine, ephedrine, mesatone, and
then to relieve spasm
pentamine, arfonad are used in peripheral vessels.
7. Changing the permeability of the vascular wall - cortisone or hydrocortisone.
8. Blockade of secretory activity of software:
for slowness acidity juice in nasogastric suction, N
2
blockers
(ranitidine)
to interrupt the synthesis of enzymes - dalargin 2 ml 2 times a day iv,
suppression of the secretion of PZ-sandostatin 0.1 mg 2-3 times a day;
protease inhibitors: contracal 80 - 120 thousand units intravenously per day for 3-5 days
to reduce secretory pressure in the ducts of PO - papillosphincterotomy, wirsungotomy.
9. Correction of immune disorders: prodigiosan 0.005% solution of 0.5 ml, thymalin, tactivin
10. Detoxification therapy:
11. antioxidant therapy: ascorbic acid 5% 10 - 20 ml intravenously for 5 days
12. oxygenation
13.Prypenennya feeding the patient through the mouth for 3 days, correction of violations
metabolism: protein at the rate of 1-2.5 g / kg per day, amino acids - up to 2 l, vitamins, ATP,
glucose
electrolyte mixtures of 1.2-2 liters, fat emulsions - up to 2 liters.
Prevention of purulent infection - antibiotic therapy. - carbapenems (500 tienam -
1000 mg 3 - 4 times a day intravenously) - fluoroquinolones II - IV generation (ciprofloxacin
- 400 mg 2
once a day, - cephalosporins III - IV generations; ceftriaxone (LENDACINE, Oframax) - 1 - 4
g1-
2 times a day
Hepatoprotectors: esensiale or heptral 5 ml 2 times a day iv, glutargin.
Surgical Techniques
1. Pancreatonecrectomy. Economical cutting of necrotic tissue ON. Cavity
washed daily as lavage, apply up to 7 liters per day of a special solution.
2. Pancreatosesecvestrectomy - in patients with acute pancreatic necrosis, hospitalized
later than 14-30 days after the rejection of sequestration. Moreover, in the presence of a
delimited
cavities provide flow drainage phlegmon and abscess - open external
drainage or programmed laparostomy using sutures that open to
tubes, zippers, while performing an audit of the abdominal cavity after 1 day, then
as necessary (only 3-9 times).
3. Resection or necrectomy of the pancreas and retroperitoneal tissue with local
laparostomy, performing pulsed lavage and the use of antibiotic powder.
Clinical task 32
A 60-year-old woman yesterday felt increasing pain in the right hypochondrium, nausea vomiting
several times, and general weakness. The body temperature got 37.5ºC. History: she is suffering from
gallstones about 10 years. The tongue is dry. The abdomen in the right hypochondrium is moderately
tense and painful. The Blumberg symptom is positive on the right.
1. DIAGNOSIS: chronic cholecystitis in the acute stage

2. Laboratory biochemical and instrumental criteria:
1. in the blood: leukocytosis (may be absent), increased ESR, eosinophilia; sometimes rise
activity of AsAT, AlAT, alkaline phosphatase, increased levels of CRP, seromucoid content,
fibrinogen, alpha2 and gamma globulins.
2. Bacteriology: inoculation of pathogens (staphylococci, streptococci, intestinal
stick, Escherichia, proteus).
3. Ultrasound thickening of the gallbladder wall (more than 4 mm) and its deformation,
violation
contractile and evacuation of its contents, changes in the shape and size of the bubble by 5 cm
more,
the presence of constrictions in the neck: compaction and / or delamination of the walls of the
organ; inhomogeneous
cavity of the gallbladder.
4. X-ray diffraction of OCP - elongation, tortuosity, uneven contrast of the cystic
duct, alternation of areas of expansion and contraction, an increase in the shadow of the
gallbladder, pain after
reception of choleretic breakfast.
5. CT - the structure of the walls of the bladder, perivesical effusion, the structure of the liver
tissue and
intrahepatic biliary tract, their size.
3.positive symptoms: 1.Mussi-Georgievsky - soreness when pressed on
phrenic nerve between the legs of the sternocleidomastoid muscle on the right;
2. Kera - Murphy - the appearance or intensification of soreness in the gallbladder on
inspiration with
pressing in the projection zone of the gallbladder with the right thumb;
3.Ortner - pain when tapping the edge of the palm along the right costal arch;
4. Lyakhovetsky - pain when pressing the right half of the xiphoid process of the sternum;
5.Mackenzie - hyperesthesia of the skin of the abdomen in the right hypochondrium with the
most pronounced
soreness in the gallbladder area.
4. Treatment of chronic cholecystitis
1 . short-term hunger with elements of parenteral nutrition. Next diet number 5 according to
Pevzner
2. The elimination of pain with antispasmodics:
● a combined preparation containing metamizole sodium, pitophenone hydrochloride,
fenpiverinia bromide, 5 ml / m, and then 1-2 tablets 2-3 times a day;
● scopolamine, 1 ml of a 1% solution in oil; in / in
● pentazocine 1-2 ml of a 3% solution;
● papaverine (drotaverinum) in 2 ml of a 2% solution in oil; in / in
● domperidone 10 mg 3-4 times a day.
● analgin - metamizole - 50% - 2.0 ml, ketorolac, iv
NaCl infusion 0.9% 800-1200 ml / day Reosorbilact 6-8 ml / kg \ Glucose 10%
3. Antibacterial therapy during an exacerbation, depending on the causative agent of the
disease in
within 7 days
1) ampicillin (amoxicillin) 500 mg 4-6 times a day orally or IM
gram-positive (streptococcus, staphylococcus) and gram-negative (E. coli,
enterococci, proteus) bacteria;
2) a combined preparation containing ampicillin and oxacillin, 500 mg 4 times a day
inside or in / m;
3) cephalosporins (cefuroxime) 250-500 mg 2 times a day;
4. Ursodeoxycholic acid 10-15 mg / kg body weight (in the presence of microliths in bile,
"Putty", gallbladder hypotension).
5 . Physiotherapeutic treatment. Physiotherapeutic treatment is resorted to in the damping
phase.
exacerbation or remission of the disease.
5.surgical treatment - laparoscopic cholecystectomy - the "gold standard
Clinical task 33
A 72-year-old female complains of pain in the right hypochondrium, nausea, and twice vomiting. She
felt ill 14 hours ago after fatty foods eating. During the last year she was periodically troubled by pain
in the right hypochondrium, but did not call a medical care. Skin has a usual color. Body temperature
is 37.5ºC. The tongue is coated, dry. The abdomen in the right hypochondrium is moderately tense
and painful. The symptoms of peritoneal irritation are negative
DIAGNOSIS: chronic stoneless cholecystitis, recurrent course, acute phase.

Laboratory biochemical and instrumental criteria:
1. ZAK: minor leukocytosis (or it is absent), increased ESR, eosinophilia;
BH - sometimes determine an increase in the activity of AsAT, AlAT, alkaline phosphatase.
2. Reactions to the inflammatory process: in the blood, increased levels of CRP, seromucoid
content,
fibrinogen, alpha2 and gamma globulins.
3. Bacteriological criteria: inoculation of pathogens (staphylococci, streptococci,
Escherichia coli, Escherichia, Proteus).
4. Ultrasound criteria: thickening of the gallbladder wall (more than 4 mm) and its
deformation, violation
contractile and evacuation of its contents, changes in the shape and size of the bubble by 5 cm
more,
the presence of constrictions in the neck: compaction and / or delamination of the walls of the
organ; inhomogeneous
cavity of the gallbladder.
5. Radiological criteria: elongation, tortuosity, uneven contrast
cystic duct, alternation of areas of expansion and contraction, an increase in the shadow of the
gallbladder,
pain after taking a choleretic breakfast.
6. CT During studies, the structure of the walls of the bladder, perivesical effusion is well
visualized,
structure of liver tissue and intrahepatic biliary tract, their size.
Palpation positive symptoms:
● Georgievsky - Musi - soreness when pressing on the phrenic nerve between
legs sternocleidomastoid muscle on the right;
● Ortner - pain when tapping the edge of the palm along the right costal arch;
● Kera - Murphy - the appearance or intensification of pain in the gallbladder on inspiration
with
● Lyakhovetsky - pain when pressing the right half of the xiphoid process of the sternum;
● Mackenzie - hyperesthesia of the skin of the abdomen in the right hypochondrium
severe soreness in the gallbladder area.
Treatment of chronic stoneless cholecystitis
Step 1. Short-term hunger with elements of parenteral nutrition. Next diet number 5 according
to Pevzner
Step 2. The elimination of pain with antispasmodics:
fenpiverinia bromide, 5 ml / m, and then 1-2 tablets 2-3 times a day;
● scopolamine, 1 ml of a 1% solution in oil; in / in
● pentazocine 1-2 ml of a 3% solution;
● papaverine (drotaverinum) in 2 ml of a 2% solution in oil; in / in
● domperidone 10 mg 3-4 times a day.
● analgin - metamizole - 50% - 2.0 ml, ketorolac, iv
NaCl infusion 0.9% 800-1200 ml / day Reosorbilact 6-8 ml / kg \ Glucose 10%
Step 3 Antibacterial therapy during the exacerbation, depending on the causative agent of the
disease in
within 7 days
1. Antibiotics, penetrate into bile in very high concentrations:
● ampicillin (amoxicillin) 500 mg 4-6 times a day orally or IM
gram-positive (streptococcus, staphylococcus) and gram-negative (E. coli,
enterococci, proteus) bacteria;
● oxacillin 250-500 mg 4-6 times a day orally or in / m;
● a combined preparation containing ampicillin and oxacillin, 500 mg 4 times a day
inside or in / m;
● cephalosporins (cefuroxime) 250-500 mg 2 times a day;
● ciprofloxacin 500-750 mg 2 times a day;
Step 4 Ursodeoxycholic acid 10-15 mg / kg body weight (in the presence of microliths in bile,
"Putty", gallbladder hypotension).
Step 5. Physiotherapeutic treatment. Physiotherapeutic treatment is resorted to in the damping
phase.
exacerbation or remission of the disease.
Step 6 in case of failure of conservative therapy in patients with stoneless cholecystitis -
surgery; laparoscopic cholecystectomy - the "gold standard"
Step 7 in the case of stoneless acute cholecystitis, effective conservative therapy -
further treatment in the therapeutic or gastroenterological departments; in case of relapse
- surgery
Clinical task 34
65-year-old man went to the admissions department with complaints of pain after a fatty meal in
the right hypochondrium. He felt ill 3 days ago. There was vomiting twice. After no-spy intake the
pain slightly decreased. Yesterday he noticed yellowing of the skin, sclera, dark urine and uncolored
feces. Body temperature is 37.2ºС. Attacks of moderate pain were before, did not call a medical care.
The tongue is coated, dry. The abdomen in the right hypochondrium is moderately painful, not tense.
Symptoms of peritoneal irritation are negative.
Diagnosis: gallstone disease, clinical stage: calculous cholecystitis,

complications obstructive jaundice
Laboratory and biochemical criteria:
● blood leukocytosis, increased ESR; eosinopenia, monocytopenia
● increased bilirubin content (mainly conjugated, direct> 17/1
mmol / l), alkaline phosphatase, cholesterol, TG, gamma globulin, positive C-reactive
protein;
● in the case of reactive hepatitis, hepatocyte cytolysis syndrome is observed (increase
ALT activity, fructose-1-phosphataldolase).
● The absence of stercobilin in feces - acholia feces
Ultrasound criteria:
● the presence of dense echo structures;
● gallstones;
● the variability of the position of the stone (there may be many, then the gallbladder may
disconnect)
● stones with a diameter of less than 3 mm or barrel-shaped stones with a diameter of 3-4 mm
(stones less than 1-2 mm
do not turn out)
● cystic duct stone;
● the walls of the gallbladder are thickened (4 mm or more).
CT criteria:
● stones that are not detected by the X-ray method are determined;
● cracks are observed in the internal structure of the stone;
● with complications of calculous cholecystitis, the presence of an abscess or fistula is
determined
(which penetrate the pancreas and intestines).
Palpation positive symptoms:
● Ortner - pain when tapping the edge of the palm along the right costal arch;
● Kera - Murphy - the appearance or intensification of pain in the gallbladder on inspiration
with
● Lyakhovetsky - pain when pressing the right half of the xiphoid process of the sternum;
● Mackenzie - hyperesthesia of the skin of the abdomen in the right hypochondrium
severe soreness in the gallbladder area.
treatment
Step 1. Short-term hunger with elements of parenteral nutrition. Next diet number 5 according
to Pevzner
Step 2. Anesthesia of an attack of biliary colic:
● papaverine in 2 ml of a 2% solution in oil;
● metamizole sodium in 2 ml of a 25% solution in oil;
fenpiverinia bromide, 5 ml iv;
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● analgin - metamizole - 50% - 2.0 ml, ketorolac,
Step 3 Surgical treatment methods:
● open cholecystectomy;
● laparoscopic cholecystectomy - the "gold standard"
● cholecystolithotomy (used in cases where it is impossible to perform
laparoscopic or open cholecystectomy, or in cases where the patient is not
agrees to the operation)
● cholecystotomy (indicated only for rapid decompression of the gallbladder in case of acute
cholecystitis).
laparotomic cholecystectomy - due to the invasiveness of the intervention is used less and
less.
Minilaparotomic accesses (4-5cm) in
right hypochondrium, however, the implementation of even planned cholecystectomy
becomes technically
rather complicated operation. Divided into cholecystectomy:
o from the neck - retrograde - after isolation of the cystic duct and artery and their constriction
the possibility of migration of calculus and purulent bile from the bladder to choledoch stops,
bleeding decreases, however, the operation becomes extremely difficult if there is
inflammatory infiltrate of hepatoduodenal communication;
o from the bottom - antegrade - to begin to emit a bubble from the bottom and secrete until
overflow the cystic duct and artery; this leads to bleeding and the risk of stone migration
and infections in the common bile duct; antegrade cholecystectomy recommended if
impossible
differentiate the structure of hepatoduodenal communication; o combined.
Step 4. Sanatorium-resort treatment in the conditions of the resorts Satanova, Truskavets,
Morshina,
Mirgorod, Berezovsky mineral waters in the period of disease remission
Clinical task 35
The patient, 66 years old, was admitted to the surgical department in serious condition.
Consciousness is confused, productive contact is not available. According to the relatives
accompanying the patient, he is suffering from gallstones about 10 years. He became ill 4 days ago.
After eating fatty foods there was pain in the right hypochondrium, vomiting. He took no-shpuni
himself. On the second day, jaundice appeared. Body temperature is 39.8ºС. Pronounced jaundice of
the skin. Blood pressure is 80/40 mm Hg, pulse rate - 138 in 1 minute. The abdomen is not swollen,
soft on palpation, painful in the right hypochondrium. Symptoms of peritoneal irritation are negative.
Per rectum - in an ampoule of a rectum fecal masses of gray - white color are issued.
The diagnosis of housing and communal services, clinical stage, calculous cholecystitis, stage
of exacerbation,
complicated by obstructive jaundice
1 Laboratory biochemical and instrumental criteria:
1 ZAK Observe neutrophilic leukocytosis, the severity of which depends on the stage
inflammatory process in the gallbladder, a shift in the leukocyte blood count to the left to
the appearance of even immature forms of granulocytes and toxic granularity of neutrophils,
lymphopenia,
eosinopenia
2 BH hyperbilirubinemia, mainly due to direct bilirubin, increased content
urea, creatinine, hyperamylasemia, a slight increase in the enzymes ALT, AST.
3 ultrasound enlarged, blocked gallbladder with thickened walls and bile calculi
4 radiological and gallstone criteria
Palpation positive symptoms
• symptom Ortner (Ortner) -Grekova - pain when tapping the palm of the hand on the right
costal
an arc;
• Murphy symptom - increased pain and break in inspiration with deep palpation in the
projection
gallbladder;
• symptom of Mussi (Mussy) - Georgievsky - when pressed between the legs of the right
sternum-clavicular-
mastoid muscle pain occurs (phrenicus symptom)
• Boas symptom (Boas) - pain when pressing with a finger to the right of the VIII-X vertebra
on
back
• Zakharyin's symptom - pain when tapping or pressing on the projection area of the
gallbladder;
• • Kera point (Kehr) - located at the intersection of the outer edge of the rectus abdominis
muscle and
costal arch - when you click in it, the patient feels pain
• Lyakhovitsky symptom - the occurrence of pain with a light pressure on the xiphoid process
due to lymphangitis and inflammatory reaction of lymph nodes located behind the xiphoid
process.
treatment
1 Functional rest for the liver and biliary tract - bed rest, local
hypothermia (cold in the right hypochondrium), hunger.
2. Silenced - in / m 2% solution of promedol.
3. Removing the spasm of the sphincter of Oddi - papaverine in 2 ml of a 2% solution in oil;
4Antibiotic therapy: cefazolin 1 g / m 2 times a day, cefuroxime 750 mg / m 2 times a day;
5 Correction of electrolyte dehydration balance and detoxification.
surgery
Cholecystectomy is the Gold Standard
open cholecystectomy
Clinical task 36
A 56-year-old patient complains of general weakness, jaundice, dark urine and white stools. Jaundice
appeared 3 weeks ago, without pain, gradually progressed. The abdomen is not bloated, soft and
painless on palpation. Symptoms of peritoneal irritation are negative. A round neoplasm of 60x50
mm is palpated in the right hypochondrium. Per rectum - white fecal masses are present in the
ampoule of the rectum.
Pancreatic head cancer complicated by obstructive jaundice

(icteric form)
diagnostics
BH Analysis allows you to determine the level of bilirubin, enzymes: lipases, amylases,
transaminases:
AsAT, AlAT, bile acids
Definition of tumor markers. Marker SA-19-9 is determined to address the issue of operability
tumors. In the early stages of cancer, this marker does NOT appear .
Ultrasound, the presence of a tumor, an enlarged gland,
CT scan that suspects cancer of the PO is a local increase in the size of the gland (90%),
tuberous contours of PO in this area (90%), the presence of a tumor-like node (85%). .
Pancreas scan
Endoscopic retrograde cholangiopancreatography procedure, during which the endoscope
used to reach the upper part of the digestive system before the onset of the small intestine.
The purpose of this method is to eliminate the blockage of the bile duct by a tumor.
Fine-needle and spiral biopsy under ultrasound control
Aortography, when the nature of the pancreatic vascular pattern is assessed
her defeat
treatment
1 use of radiation therapy, and chemotherapy, are applied comprehensively. To operation - for
reduce the size of the neoplasm and after surgery - to destroy small foci of cancer
cells and inhibiting the re-development of the tumor. ( (5-fluorouracil, calcium folinate,
doxorubicin, mitomycin)
Depending on how cancer cells have spread in the affected organ,
the following types of operations are carried out:
Pancreatoduodenectomy (Whipple procedure). During the operation, the head of the gland,
the bile, is removed
a bubble with ducts, part of the stomach and small intestine, separate sections of the lymph
nodes. Then
new digestion patterns are being formed.
Distal pancreatectomy. It provides for the removal of the body of the gland and its tail,
leaving the head.
Total pancreatectomy. Complete organ removal. To date, enough
rarely.
After removal, patients take lifelong drugs that replace digestive
enzymes, as well as insulin.
Clinical task 37
A 47-year-old woman woke up with severe pain in her right iliac region and lower abdomen. She
noticed dry mouth. The temperature did not rise. At dynamics after 2 hours: positive symptoms of
Voskresensky and Bartomier-Michelson. The symptoms of peritoneal irritation are negative. WBC
and leukocyte formula are within normal limits.
1. DIAGNOSIS: Acute appendicitis uncomplicated

2.
Rowzing symptom: with the left hand, the sigmoid colon is fixed through the anterior
abdominal wall to
iliac wing, left right hand above this place carry jerky
movement of the abdominal wall. When gases move in the colon, pressure increases in
the area of the mouth of the appendix, accompanied by increased pain in the right iliac
area;
Sitkovsky's symptom - increased pain in the right iliac region in the patient’s position on
left side. In this case, the cecum is discharged medially and entails a lit
appendix;
Symptom Obraztsova - II-III fingers of the right hand slightly press the abdominal wall in the
right
iliac region, then ask the patient to raise the straightened right leg - there is pain in
right iliac region.
symptom of Zhendrinsky - differential. diagnosis between acute appendicitis and acute
salpingo-oophoritis: in the supine position, pressure on the abdominal wall at the point of
Kümmel (2 cm to the right
and below the navel), finger and, without taking it away, offer the patient to stand up. Pain
enhancement
indicates appendicitis, a decrease - of acute salpingo-oophoritis.
KLA: the vast majority of patients revealed moderate leukocytosis, a shift is possible
leukocyte formula to the left (but may not be).
BH: In almost all patients with acute appendicitis, an elevated level of C- is recorded.
reactive protein
Ultrasound: Signs of acute appendicitis are an increase in the diameter of the appendix,
thickening of its wall, rigidity when applying dosed compression to the front
abdominal wall, the presence of free fluid in the right iliac region.
3. Treatment
conservative treatment
- limited motor mode;
- A complete high-calorie diet with the exception of foods rich in fiber;
- local treatment - cold to the right iliac region with local signs
irritation of the peritoneum (0.5-1.5 days), after the elimination of the latter - heat (grill, UHF)
- complex antibacterial therapy (parenteral is better) aimed at suppressing
colonic flora gentamicin 2 mg / kg (in children 6-7.5 mg / kg / day) and metronidazole 7.5 mg
/ kg (in
children 15-30 mg / kg / day, max. 2 g / day). If there is no perforation, antibiotics are used up
to 24 hours
after operation; in other cases - within 5 days.
- detoxification infusion therapy (osmotherapy, stimulation of diuresis in the first days)
1) It consists in the early removal of the appendix - appendectomy. (First 2:00) This
surgical intervention is performed under general anesthesia. The operation may be open and
laparoscopic.
The Classical Surgical School provides two methods for the removal of a cranium germ
from the apex (antegrade) from the base (retrograde) in particularly difficult cases - lobar. At
open access, the typical location of the incision is the right iliac site, access by Volkovich
-Dyakonovim, (Volkiewicz-Mac-Brunei) or Lenander; in complex cases of diffuse peritonitis
median laparotomy is performed .
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operation stages
● Layered incision and separation of tissues of the anterior abdominal wall (in the incision
area)
● Mobilization of the appendix
● clamping and cutting off the appendix, dressing his cult
● An immersion of the appendix stump into the cecum can be performed, followed by
application
immersion seams
● Audit of the abdominal organs ( drainage if necessary )
● Layer stitching of the postoperative wound
2) gentamicin 2 mg / kg (in children 6-7.5 mg / kg / day) and metronidazole 7.5 mg / kg (in
children 15-30 mg / kg /
day max 2 g / day). If there is no perforation, antibiotics are used up to 24 hours after
surgery; at
other cases - within 5 days
Clinical task 38
A 50-year-old patient complains of pain in the right lower abdomen, lack of appetite, weakness. 5
days ago he noted chest pain, nausea, one-time vomiting. After a few hours, the pain moved to the
right iliac region. Objectively: body temperature is 37.8ºC. Palpation of the abdomen: in the right iliac
region there is a formation 90x80 mm, moderately painful, immobile. At percussion: the dull
percussion sound is defined over it. Auscultation: the expressed intestinal noises. PS 88/1 min.
1. DIAGNOSIS: Appendicular infiltrate

2. Subjective symptoms:
- suffered an attack of acute appendicitis a few days ago with subsequent improvement
general condition;
- moderate constant pain in the right iliac region, which may be somewhat worse with
movement and coughing.
Objective signs:
- low-grade body temperature (up to 38-38.5 ° С);
- adequate tachycardia for body temperature
- in the right iliac region (or in another, depending on localization and position
the appendix in a particular patient against a background of varying degrees of tension
muscles of the abdominal wall and inflammatory signs of peritoneal irritation) can be palpated
to determine the tumor formation of irregular shape with more or less clear contours,
not quite smooth surface, dense, small or immovable, sick, size from 3-4 to 10-12
cm;
- the same tumor formation can be determined during vaginal or rectal
research;
KLA: moderate leukocytosis with a slight shift of the leukocyte formula to the left, some
increase in ESR.
3. Conservative treatment of infiltrate. Prescribe bed rest, antibiotics,
anti-inflammatory, physiotherapeutic procedures. Before prescribing such therapy
the tumor process should be excluded. 2-2.5 months after resorption of the infiltrate
planned appendectomy is indicated. If an abscess has occurred, infiltrate is performed
autopsy of the abscess with extraperitoneal access, antibiotic therapy is performed. In case of
detection
appendicular infiltrate during surgery, then limited to abdominal drainage
cavity, the introduction of antibiotics into it. Further treated conservatively.
Clinical task 39
The patient, 58 years old, complains of abdominal pain. Three days ago there was a sharp pain in the
epigastric region, nausea, there was a single vomiting. After a few hours, the pain moved to the right
iliac region and became less intense, 4 hours ago, the pain intensified significantly and gradually
spread throughout the abdomen. On examination: the patient is excited, with a feverish spotі on the
cheeks, pulse rate is 100 beats / min. Body temperature - 38.4 ° C. The right half of the abdomen
does not participate in respiration. On palpation of the abdomen - a pronounced protective muscle
tension. The Blumberg symptom is sharply positive. Intestinal murmurs are not heard.
Diagnosis: Acute appendicitis (gangrenous?). Complications: perforation of the appendix

diffuse peritonitis.
1. ZAK: leukocytosis, a shift of the leukocyte formula to the left, an increase in ESR + an
electrolyte imbalance,
dysproteinemia, slight azotemia (signs of peritonitis)
2. BH: elevated levels of C-reactive protein
3. WAS: red blood cells, if the appendix is located close to the ureter or bladder.
albuminuria, cylindruria (signs of a toxic process with peritonitis)
4. Ultrasound: at the point of Mc Burney a rounded hypoechoic shadow with hyperechoic
internal structure -
symptom of "cockade", fecal stones, bloating of the intestinal loops in the right iliac region,
horizontal fluid level in the cecum, exudate in the abdominal cavity.
5. Laparoscopy - with a vague diagnosis
Positive symptoms of peritoneal irritation:
• From Sitkovsky - after the patient turns from the back to the left side, pain in the right
the ileal area is amplified. The mechanism of development is associated with the movement of
the cecum
and the appendix to the left and the mesentery of the latter;
• S. Ivanova - it’s less than the distance from the navel to the anterior superior iliac spine than
left. Symptom occurs due to muscle contraction in the right iliac region;
• S. Rozanova - a patient lying on his back, is asked to exhale air and immediately do
additional exhalation: the patient cannot exhale additional air due to pain,
because for this it is necessary to strain the muscles of the anterior abdominal wall. Symptom
allows you to differentiate the presence of an inflammatory process in the abdominal cavity or
beyond
outside (pleurisy, pneumonia).
• St. Mendel - with a light tapping with your fingertips on the anterior abdominal wall
there is pain just above the place of accumulation of fluid or a source of inflammation.
• S. Rozdolsky - with a hammer percussion of the anterior abdominal wall above the source
inflammation occurs or pain intensifies ..
• S. Shchetkina - Blumberg - with gradual fingers pressing on the patient’s abdominal wall
feels increased pain (Mortola symptom), and if you instantly take your hand from the
abdomen, then
there is pain too pronounced.
• Voskresensky (“shirt”) - with rapid movement of the hand on the skin or shirt
pressing the abdominal wall of the patient, from the epigastric region (from the xiphoid
process) to
right, left iliac, or to the pubis there is pain in the area where
peritoneum.
• S. Mortola - while gradually pressing with fingers on the abdominal wall, the patient feels
increased pain
• St. Madelung - the difference in body temperature in the axillary fossa and the rectum is
more than 2 degrees.
• “Douglas Scream” - severe pain with a digital examination of the rectum or
bimanual gynecological examination.
treatment:
Emergency surgery - median laparotomy, pour into the abdominal cavity
400 ml of a 0.25% solution of novocaine or 200 ml of this solution is injected into the root of
the mesentery thin
intestines, primary cleaning and revision of the abdominal empty, elimination of the source of
infection
(appendectomy), sanitation of the abdominal cavity, drainage.
Infusion therapy: 7.5-10% sodium chloride solution at the rate of 2 ml / kg / 30 min.
Colloidal solutions, in particular HES (HES): Reftan N HES 6% (6-8 ml / kg), Stabizol (8-10
ml / kg) from 500 to 1000 ml / day and crystalloid solutions in a ratio of 1: 1.
Antibiotic therapy: Carbapenems (Tienam vv 1000 mg with anesthesia and 1000 mg after 3
h, Imipenem, Meronem)
Clinical task 40
A 72-year-old patient was brought to the surgical department with a clinical picture of strangulated
right inguinal hernia. Emergency surgery was offered; but the patient set in the hernia himself,
refused the operation and left the hospital without permission. He was brought to the hospital again
in 18 hours. The patient's condition is severe, pulse 100 beats. per 1 min., the tongue is dry, the
abdomen in the lower areas is sharply painful, the symptoms of peritoneal irritation are positive.
Diagnosis: Constrained right-sided inguinal hernia. Complications: intestinal gangrene,

diffuse
peritonitis
1. ZAK: leukocytosis, a shift in the leukocyte formula to the left, an increase in ESR, an
electrolyte imbalance,
dysproteinemia, azotemia
2. BH: elevated levels of C-reactive protein
3. WAS: albuminuria, cylindruria
4. Ultrasound.
4. Intraoperative diagnostics
Positive palpation symptoms:
• SM "cough push"
• St. Mendel - with a light tapping with your fingertips on the anterior abdominal wall
there is pain just above the place of accumulation of fluid or a source of inflammation.
• S. Rozdolsky - with a hammer percussion of the anterior abdominal wall above the source
inflammation occurs or pain intensifies.
• S. Shchetkina - Blumberg - with gradual fingers pressing on the patient’s abdominal wall
feels increased pain (Mortola symptom), and if you instantly take your hand from the
abdomen, then
there is pain too pronounced.
• Voskresensky (“shirt”) - with rapid movement of the hand on the skin or shirt
pressing the abdominal wall of the patient, from the epigastric region (from the xiphoid
process) to
right, left iliac, or to the pubis there is pain in the area where
peritoneum.
• S. Mortola - while gradually pressing with fingers on the abdominal wall, the patient feels
increased pain
Treatment: emergency surgery - median laparotomy, in the abdominal cavity
400 ml of a 0.25% solution of novocaine are poured or 200 ml of this solution is injected into
the mesentery root
small intestine, primary cleaning and revision of the abdominal empty, identify affected
organs, elimination of the source of infection (resection of a non-viable colon), rehabilitation
abdominal drainage.
Plastic hernia gates.
Infusion therapy: 7.5-10% sodium chloride solution at the rate of 2 ml / kg / 30 min.
Colloidal solutions, in particular HES (HES): Reftan N HES 6% (6-8 ml / kg), Stabizol (8-10
ml / kg) from 500 to 1000 ml / day and crystalloid solutions in a ratio of 1: 1.
Antibiotic therapy: Carbapenems (Tienam vv 1000 mg with anesthesia and 1000 mg after 3
h, Imipenem, Meronem)
Clinical task 41
A 58-year-old patient was taken to the surgical department with complaints of pain in the area of
the right inguinal-scrotal hernia. Patient has this hernia during last 10 years. 3 days ago, after
exercise, the hernia stopped to set in, there was pain, nausea, and vomiting, then swelling, redness
of the scrotum. Temperature got to 38 ° C. Objectively: the general condition is several; pulse rate is
95 beats for 1 min., blood pressure - 110/70 mm Hg. A tongue is dry. Abdomen is soft in the lower
areas, moderately painful; symptoms of peritoneal irritation are negative. The scrotum is enlarged,
hyperemic, infiltrated, sharply painful on palpation.
1) Diagnosis - Infringement of a right-sided inguinal-calico-hernia (oblique, because it goes

into
a gate - through a lateral inguinal fossa !!! Direct not released into the scrotum)
2) Laboratory and instrumental criteria
Laboratory diagnostics: at the initial stage, there are no changes ( during storage of viability
intestines) , then inflammatory changes in the blood grow (leukocytosis with a shift in
leukocyte
formulas to the left), water-electrolyte disturbances (hypokalemia, signs of dehydration
according to P.I.
Shelestyukom), hypercoagulation.
Instrumental diagnostics: not needed at the initial stage. In doubtful cases - review
abdominal radiography: arches with horizontal fluid levels (bowls
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“Kloiber”), stretching the Kerking folds in the form of a spring, the absence of thick
pneumatization
guts.
Symptom of a negative cough push (if you close the hernia gate with your finger and force
cough the patient, the researcher will not feel the tremors from the blow of the hernial
contents)
3) Tactics and treatment
Emergency surgery
1. Intubation and decompression of the stomach
2. Premedication (diazepam solution 0.5% 2 ml s)
3. Antibiotic prophylaxis with cephalosporins of 1 or 2 generations (Cefazolin 2 g centuries,
or
Cefuroxime 1.5 g / m) - before surgery.
4. Prevention of thromboembolic complications (sodium heparin solution 5000 PIECES sc in
2 times
day for 7 days)
5. Operation
Stage 1 (layered dissection of tissues before aponeurosis and exposure of the hernial sac)
Stage 2 (opening the hernial sac)
Stage 3 (dissection of the snap ring)
Stage 4 (determination of the viability of impaired organs - pink color of the small intestine,
presence
pulsations of the vessels of the mesentery, the absence of strangulation sulcus and subserous
hematomas,
restoration of peristaltic contractions of the intestine)
Stage 5 (resection of a non-viable colon - at least 30-40 cm of the lead loop and 10 cm of the
discharge
loops)
Stage 6 (plastic hernia gate - Bassini method - reinforcing the posterior wall of the canal -
under the seed
with a cord hem the lower edge of the internal oblique and transverse muscles together with
the transverse
fascia of the abdomen to the inguinal ligament. The method of Kukudzhanov, Liechtenstein,
Spasokukotsky)
6. Postoperative infusion therapy (Glucose solution 10% 500 ml cc 2 times for 2
days; Sodium chloride solution 0.9% 500 ml cc 2 times for 2 days.)
8. Stimulation of peristalsis (at the end of the second - the beginning of the third day):
Neostigmine solution
0.05% 1 ml s / c 2 times.
9. NSAIDs (Ketoprofen solution 5% 2 ml IM 3 times for 3 days.)
Clinical task 42
A 50-year-old patient is operated for a strangulated right side inguinal hernia. After opening the
hernia sac, two loops of the small intestine were found, which are viable in appearance.
1) Diagnosis - impaired right-sided inguinal-Kalitkov hernia

2) During surgery for a strangulated right-sided inguinal-kalitikovoi
hernias were found two loops of the small intestine, which in appearance are viable.
That is, they had a pink color, there was a pulsation of the vessels of the mesentery, the
absence of
strangulation sulcus and subserous hematomas, peristaltic resumed
bowel contractions.
3) The further course of the operation - plastic hernia gate - Bassini method - reinforcement of
the back
channel walls - the lower edge of the internal oblique is sutured under the spermatic cord and
the transverse muscle along with the transverse fascia of the abdomen to the inguinal
ligament. Way
Kukudzhanov Spasokukotsky, Liechtenstein - put a polypropylene mesh in
spermatic cord and fisu uninterrupted suture to the lateral edge of the rectus abdominis muscle
and axillary connection, and the inner edge of the mesh is hemmed to the internal oblique and
transverse
muscle)
4) Postoperative infusion therapy (Glucose solution 10% 500 ml cc 2 times for 2
days; Sodium chloride solution 0.9% 500 ml cc 2 times for 2 days.)
5) Stimulation of peristalsis (at the end of the second - the beginning of the third day):
Neostigmine solution
0.05% 1 ml s / c 2 times.
6) NSAIDs (Ketoprofen solution 5% 2 ml IM 3 times for 3 days.
Clinical task 43
The patient is 68 years old, hospitalized with a clinic of gastrointestinal bleeding. Ill acutely,
complains of defecation with blood clots, as well as bright red blood. In the anamnesis: appetite is
good, has not lost weight in these latter months, suffers from hypertension, for 3-4 years notes the
appearance of periodic pain in the left iliac region of the abdomen with dysfunction of the colon in
the form of constipation, alternating with diarrhea. Objectively: skin and mucous membranes pale,
breathing rate 20 / min., blood pressure 180/110 mm Hg, pulse 92 /min. The tongue is moist, the
abdomen is soft and painless. Symptoms of peritoneal irritation are negative. St. localis: skin in the
anus without features. Per rectum: sphincter tone is sufficient, in the anal canal without pathology,
fresh blood on a glove.
Diagnosis: diverticulosis complicated by bleeding.

▪ Complete blood count. Red blood cell and hemoglobin levels can be reduced with
bleeding from diverticula. With diverticulitis, the level of leukocytes is increased.
▪ Erythrocyte sedimentation rate (ESR). With diverticulitis, it can be increased.
▪ C-reactive protein. An increase in its amount is characteristic of acute inflammation.
▪ Fecal occult blood test. A positive result may indicate internal
bleeding in the gastrointestinal tract.
▪ Diagnosis: includes bloody stools, abdominal pain, and diarrhea . Diagnosis
confirmed when erythematous is detected during endoscopy,
loose and granular mucous membrane with diffuse or heterogeneous
distribution, including the mucous membrane of the inter-diverticular
space.
▪ irrigoscopy - an X-ray examination of the colon with the introduction of
using an enema of an radiopaque drug. Allows exploring the terrain
colon mucosa and reveal diverticula.
▪ Sigmoidoscopy is a visual examination of approximately 30 cm of the colon
with the help of a sigmoidoscope - a tube with a light source.
▪ colonoscopy involves examining the colon by introducing the probe through the straight
the gut.
▪ Ultrasound examination (ultrasound).
▪ Computed tomography. With its help, you can not only identify the diverticulum, but also
determine the presence of inflammatory thickening of its wall, abscesses.
Treatment
-Hemostatics (Vikasol)
- transfusion of freshly frozen plasma
- ACE inhibitors (Analapril)
Antispasmodics (drotaverinum)
- Sulfalase drugs
- Dynamic monitoring of the patient in case of relapse of bleeding urgent
operation "left-sided hemicolectomy"
During abdominal surgery, a peritoneal incision is made, providing direct access to
lesions of the intestine.
With laparoscopic surgery, small sections of the abdominal wall are performed. To the
abdominal
carbon dioxide is injected into the cavity, then a thin tube with a miniature video camera is
introduced
at the end. The operating field is displayed on the screen.
During the intervention, a resection of the affected area of the intestine is performed, then the
ends are connected
in such a way as to ensure continuity of the gastrointestinal tract. In some
in cases a temporary or permanent stoma is necessary.
Cuts in the abdominal wall are either sutured or stapled with surgical staples. After two
weeks stitches are removed.
Clinical task 44
The 48-year-old ambulance patient was delivered to the surgical department with complaints of pain
in the left iliac region of the abdomen, bloating, nausea, lack of bowel movements for two days and
fever up to 37.2 ° C. The duration of the disease are 3 days. In the anamnesis: suffering from the
diverticular disease of the colon, during the last two months there was periodic abdominal pain of
this localization and constipation. Objectively: the general condition is satisfactory, the skin and
mucous membranes of normal colour, moist. Vesicular respiration in the lungs. BP 110/75 mm Hg,
pulse 86 / min. The tongue is wet with a moderate white plaque. The abdomen is symmetrical,
moderately swollen, the left iliac region is slightly behind in the act of breathing from other
departments. On superficial palpation in the left iliac region observed local muscle tension, a weakly
positive symptom of peritoneal irritation, is palpated a painful infiltrate measuring 8 × 10 cm.
Pasternatsky's symptom is negative on both sides.
Diagnosis: Diverticulosis disease complicated by paracolic infiltrate

Symptoms: fever, leukocytosis, diarrhea, mucus and blood in the stool, persistent flatulence.
Accelerated ESR
Diagnosis: ultrasound of abdominal cavity oracles, OAC, biochemistry (increase in C-reactive
protein),
analysis of feces for occult blood.
Irrigography - an x-ray study with contrasting the large intestine, after
which diverticulum is well visualized .
Colonoscopy - a study using a flexible colonoscope that allows you to examine the entire
colon mucosa and reveal its changes, diverticula.
Treatment
-Hemostatics (Vikasol)
- transfusion of freshly frozen plasma
- Ciprofloxacin (1000)
Antispasmodics (drotaverinum)
- Sulfalase drugs
Operation: surgical intervention with resection of the diverticulum affected segment is
required
colon and with the imposition of a primary anastomosis.
Hartmann's operation:
the abdominal wall is dissected from the upper edge of the pubic bone to the navel. After
access to the abdominal
cavity and a thorough examination of the organs accessible for this begins preparation of the
affected
site to be removed. It consists in the dissection of the peritoneum, peeling the rectum from
sacrum, intersection of ligaments and ligation of blood vessels that feeds the removed area
Clinical task 45
The patient is 45 years old, a sailor by profession, after six months of swimming against the
background of good health accidentally found blood in the stool. He did not go to the doctors. In 2-3
weeks after lifting weights, He felt a sharp deterioration in health. The patient began to tire often, his
appetite worsened, He developed joint pains and painful bluish-pink nodules on both legs,
protruding above the skin. And frequent stools with painful tenesmus up to 10-15 times with mucus
and blood. Objectively: pale skin, erythema nodosum on legs, body temperature 37.8 ° C. Vesicular
respiration. Rhythmic heart tones, tachycardia, heart rate 89 / min. Palpation shows pain in the
course of the colon, the sigmoid is spasmodic. There are no symptoms of peritoneal irritation.
Diagnosis: UC, severe severity (steroid-dependent or not, it is not yet possible to say for sure)
Diagnosis: In a clinical blood test - signs of inflammation (increase in total
leukocytes, stab leukocytes, platelets, increased ESR) and anemia (decreased level
red blood cells and hemoglobin). In a biochemical blood test - signs of an inflammatory
process
(increased levels of C-reactive protein, gamma globulins), anemia (decreased levels
serum iron), immune inflammation (Elevated circulating immune complexes,
class G immunoglobulins). Fecal analysis - the exception of infectious, bacterial infection and
helminthic infestation. Endoscopic examination - continuous (continuous) is detected
inflammation of the colon mucosa, almost always starting in the rectum, in about 50%
cases spreading proximally. The terminal ileum is involved
rarely (reflux ileitis). Fecal markers of intestinal inflammation (calprotectin, lactoferrin,
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lysozyme or elastase). X-ray is a symptom of water pipes (lack of folds in the gut).
Histological - violation of the architectonics of crypts, cr abscesses, transmural inflammation
mucous membrane, edema and infiltration of lymphoid and plasma cells of the submucosal
layer,
hyperplasia of lymphoid follicles and Peyer's patches, granulomas. With progression
suppuration diseases, ulceration of lymphoid follicles, the spread of infiltration to all
layers of the intestinal wall, hyaline degeneration of granulomas. Treatment: Diet No. 4 (b,
c). 5-
aminosalicylic acid: mesalazine or sulfasalazine. 5-ASA at a dose of> 3 g / day. System
corticosteroids (prednisone, prednisolone, methylprednisolone) are used if symptoms
active colitis is NOT stopped by mesalazine. The initial dose of 40 mg of prednisone per day,
in
further reduced by 5 mg / day at weekly intervals. With moderate severity
activity of 20 mg / day for 4 weeks, then reduced to 5 mg / day per week. For
prevention of hormonal resistance or dependence on treatment, cytostatics are added
(methotrexate, azathioprine, 6-mercaptopurine, cyclosporine) Thiopurins. Azathioprine or
mercaptopurine is prescribed to maintain remission achieved with steroid use
Monoclonal antibodies to TNF-ɑ (infliximab, adalimumab, golimumab and cetrolizumab
Pegol).
Surgical treatment: Emergency indications for surgical treatment of AS (colectomy)
are: toxic dilatation, perforation, massive bleeding, no improvement in
severe disease with adequate therapy (including intravenous administration
steroids) for 7 days. Planned indications include: severe course AS in the absence
the effect of conservative therapy with disease progression, frequent relapses,
significantly worsening quality of life, high-grade dysplasia or carcinoma. At
the development of acute complications AS the priority is to perform colectomy surgery with
the formation of an ileostomy, which subsequently allows reconstructive
recovery operation. Due to the severity of the patient’s condition, colproctectomy surgery,
even
if absolute is indicated for rectal removal, it should be considered NOT acceptable due to
great her injuries. One of the complications of colectomy, significantly impairing quality
life, is inflammation of the ileoanal pocket (spider)
Clinical task 46
The patient is 43 years old, 2 months ago she saw blood impurities in faecal masses. From the
anamnesis: for many years suffering from constipation, the father of the patient at the age of 40 died
of colorectal cancer (inoperable). On examination: satisfactory condition, the skin of normal colour,
peripheral lymph nodes are not enlarged. In the lungs without pathology. The heart rate of 72 / min,
blood pressure - 130/80 mm Hg. The tongue is wet and clean. The abdomen is soft, painful in the left
mesogastric region. The liver is not enlarged. At finger research of rectum: the lower pole of dense
tumorous formation on a back wall is palpated, on a glove - blood.
Diagnosis: neoplasms of the rectum (most likely malignant neoplasm)

Diagnosis: occult blood test (blood culture test)
Ultrasound (ultrasound). This examination allows you to find out how much the tumor has
stuck.
through the wall of the intestine, whether there are neoplasms in neighboring tissues,
metastases in the lymph nodes .
Oncomarkers make it possible to determine the degree of activity of tumor cells.
MRI most accurately shows the picture of the presence of tumor processes in the pelvis. it
the study is mandatory with confirmation of the need for chemoradiotherapy before
operation.
Colonoscopy / sigmoidoscopy is the only and most informative way to make sure
the presence of neoplasm in the rectum. An endoscope is inserted into the anus for
examination.
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the inner surface of the intestine, previously cleansed by an enema or laxatives. During
procedures the doctor Not only takes tissue samples, but can also remove detected polyps.
Treatment: The main treatment method is surgical.
Preparation of the intestine for surgery - orthograde washing by introducing 6-8 l of isotonic
r-
RA through a probe Installed in the duodenum 12.
With a tumor of the submucosal, mucous layers of the intestine, only surgery is performed
intervention. If a small rectal cancer, its removal is carried out with
using a colonoscope through the anus. When performing surgery for colorectal cancer
the tumor can be removed by transanal endomicrosurgery. When a tumor enters
muscle layers surgery is performed with complete or partial excision
the affected area. A combined operation is prescribed when to nearby organs
tumor cells spread. The operation is carried out in a single unit. In case of intrusion
metastases in the ovaries, lungs, liver, etc. At the medical consultation, the question of Phased
or their simultaneous resection.
Radical rectal surgery focused on removal of the tumor and regional
lymph nodes. The choice of radical surgery method is determined by the distance
lower border of the tumor from the anus. The most commonly used abdominal
perineal extirpation of the rectum (less than 6-7cm from the anus), anterior resection
rectal Dixon surgery (10-12 cm), abdominal-anal rectal resection with
reduction of the sigmoid colon (or transverse colon) of the intestine (more than 6-7 cm from
the back
passage), Hartman's operation (obstructive resection) - if it is impossible to perform the
anterior
rectum resection
Clinical task 47
The patient is 55 years old, 3 months ago he first saw blood impurities in the stool, before that
during the year he was worried about constipation, pain in the left iliac region. On examination:
satisfactory condition, moderate nutrition. In the lungs without pathology. Heart rate 76 / min.,
Blood pressure 140/90 mm. Hg. The tongue is moist. The abdomen is not swollen, painful on
palpation in the left iliac region, where a dense tumour up to 5 cm in diameter is palpated. Liver
along the edge of the costal arch. It is not revealed at rectal research of pathology. At
fibrocolonoscopy: on 25 cm from an anus a cup-shaped tumor to 4 cm. Histologically: moderately
differentiated adenocarcinoma of a large intestine. At irrigoscopy in the average third of a sigmoid
gut defect of filling within 5 cm. At ultrasonography of an abdominal cavity of data on metastasises
has no. During the lower middle laparotomy, a tumour was detected in the middle third of the
sigmoid colon, which grows into the serous membrane, in the left lobe of the liver on the
diaphragmatic surface revealed 2 metastatic nodes 1.5 cm in diameter.
Diagnosis : Stage 4 sigmoid cancer with liver metastases.

The help of examinations and symptoms: from the anamnesis: constipation worried for a year,
stayed in the left
zduhv.dilyantsi, an admixture of blood in feces, palpable tumor up to 5 cm in diameter in the
left iliac
areas are all signs of a sigmoid colon tumor, rectal examination is
basic in a patient with a pathology of the large intestine and is direct screening cancer
intestines in patients 50+ years old, fibrocolonoscopy and irrigoscopy are the main
clarification and diagnosis associated with cancer of the rectum and sigmoid colon (mainly
way), a filling defect with irrigoscopy is a sign of exophytic tumor growth, ultrasound OBP -
for the diagnosis of metastases in the abdominal cavity, 2 nodes in the liver - signs of
metastasis
tumors and characterization as malignant. Tactics and treatment: surgical treatment -
operation
Hartmann. Performed in two stages, the 1st stage: the elimination of obstruction, the resection
of the affected
plot, creating a colostomy. 2nd stage: closure of the colostomy and restoration of intestinal
continuity
Clinical task 48
A 33-year-old patient was treated in a surgical hospital for acute destructive pancreatitis 3 months
ago. Conservative therapy was performed, the condition improved. Complains of moderate, dilating
pain in the epigastrium, noticed moderate yellowing of the skin, sclera, dark urine. Body temperature
is 37.2ºС. Tongue is coated, wet. The abdomen in the right hypochondrium is moderately painful, not
tense, tumor-like formation 80 * 70 mm is palpated. It is densely elastic consistency, immobile.
Symptoms of peritoneal irritation are negative.
Diagnosis: chronic pancreatitis, stage of exacerbation, post-necrotic cyst of the head p / s,

obstructive jaundice.
Help examinations and symptoms: bursting pains in the epigastrium, yellowing of the skin,
sclera,
dark urine - signs of bile duct obstruction, tumor-like palpable
education in the right hypochondrium is a symptom of Courvoisier (enlarged and painless are
palpated
gall bladder), is a sign of overlap of the common bile duct (cyst or possibly tumor
heads p / s)
Tactics and treatments: Surgical treatment. There are several possible options:
1. Internal surgical drainage (pancreatocystogastrostomy,
pancreatocystoduodenostomy or pancreatocysteojunostomy)
2. external surgical drainage (less useful, often leads to external
pancreatic fistula)
Clinical task 49 Patient P. is 36 years old, by profession is an IT engineer. 25 days ago was discharged
from the gastroenterology department in satisfactory condition, where for 18 days he was treated
for duodenal peptic ulcers up to 1.8 cm in diameter. During the last week, general weakness, fullness
in the epigastric region, intermittent pain began in the upper abdomen. Nausea, belching with an
unpleasant "rotten" smell of hydrogen sulfide, vomiting several times a day, which brings relief, are
present. On examination: Height: 175 cm, weight: 63 kg. The skin is moderately pale, dry, clean,
turgor and elasticity are reduced. Vesicular respiration is in the lungs. BF is 18 per minute. Heart
tones are rhythmic, clear. Pulse rate - 78 / min, blood pressure - 130/85 mm Hg. The tongue is
covered with a grayish layer, dried. The abdomen is soft, symmetrical, participates in the act of
breathing, moderately painful in the epigastrium, where Vasylenko (fluctuations) symptom is
determined. Liver and spleen are normal. Symptoms of peritoneal irritation are negative.
Pasternatsky's symptom is negative on both sides. During the last two days, gastric lavage was
performed on an empty stomach. 500 ml of stagnant gastric contents with snippets of food were
aspirated. Fecal analysis - Gregersen's reaction is negative.
1. Diagnosis - Pyloroduodenal stenosis, stage of compensation

2. Diagnostic methods
-Laboratory examination methods
Complete blood count - signs of dehydration, there may be a decrease in hemoglobin and
increase in ESR;
Biochemical blood test (bilirubin, total protein, sugar, potassium,
Sodium, calcium, chlorine, creatinine, urea, amylase,
AsAT, AlAT, alkaline phosphatase)
- Observe hypokalemia, hypochloremia, hypoproteinemia,
Increased creatinine, urea nitrogen; in the study of pH and gases
Blood ascertain metabolic alkalosis, which changes by a decrease
pH coagulogram; general clinical analysis of urine (hematuria,
albuminuria, cylindruria).
-When x-ray examination in the stage of compensation
They show a normal size or slightly enlarged stomach,
Strengthening of its peristalsis, narrowing of the pyloroduodenal zone.
Complete evacuation of contrast from the stomach is slowed down to 6-12 hours.
Endoscopic fibrogastroduodenoscopy (EFGDS)
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An endoscopic examination determines the degree of narrowing of the pyloroduodenal zone,
determine the condition of the mucous membrane and size
The stomach, there is also the opportunity to conduct a biopsy for histological
Verification of the diagnosis.
In the stage of compensation with EFGDS note scar-ulcer
Deformation with narrowing of the pyloroduodenal zone to 0.8-1 cm.
The peristalsis of the stomach is normal.
Ultrasonography (USG) and computed tomography (CT)
With compensated pyloroduodenal stenosis, it is echographic
The picture of the stomach on an empty stomach does not differ from that of patients with a
peptic ulcer
The disease. After fluid intake, you can determine the deformation,
Thickening of the wall and the size of the clearance at the site of narrowing
Pylorobulbar zones.
Pyloroduodenal stenosis of ulcerative origin
Differentiate with stenosis due to output tumors
Stomach or pylorospasm
3.Likuvannya
Patients with exacerbation of peptic ulcer conduct a course
Intensive conservative antiulcer treatment over
2-3 weeks.
-In the preoperative period carry out infusion therapy of water-electrolyte metabolism with
the introduction of complex saline solutions, albumin, blood plasma.
The complex of infusions include:
1. Hemodynamic, which include low molecular weight dextrans (reopoliglyukin),
medium molecular dextrans (polyglucin) and gelatin preparations (gelatin).
Increase bcc, increase blood pressure, improve microcirculation.
2. Detoxification (neogemodez, polydez, neocompensated).
3. Preparations for parenteral nutrition: protein (casein hydrolyzate, aminopeptide,
nitrolysin), amino acid (polyamine, infezol, freeamine), fat (lipofundin,
librolipid) and hydrocarbon (glucose, sorbitol, fructose).
4. Regulators of the water-salt and acid-base conditions: saline solutions (solution
sodium chloride, Ringer-Locke solution, disol, trisol) and osmodiuretics (mannitol,
sorbitol).
5. Drugs with the function of oxygen transfer (perfluorane, foliosol) - bind (2-3 times
better than Hb) and transport oxygen.
6. Preparations of complex action (polyphore, reogluman, lactoprotein, rheosorbylact).
- These patients are given full antiulcer treatment -
Triple therapy aimed at eradicating Helicobacter pylori infection
And a decrease in acidity. (Clarithromycin 500 mg 2 r / d, amoxicillin 1000 mg 2 r / d, omez
20 mg 2r
/ d)
- Systematic decompression of the stomach - gastric lavage and gastric aspiration
Content through the probe.
An effective treatment is enteral nutrition (probe
Or through eunostomom).
- Carries out die cutting of scar tissue, which caused pyloric stenosis with emergency
Clinical task 50
The patient is 51 years old. Hospitalized to the surgical department with complaints of general
weakness, fatigue, heaviness in the epigastric region, rapid satiety with food, intermittent pain in the
upper abdomen after eating, nausea, belching with the smell of hydrogen sulfide, frequent vomiting
with not digitated foods. He suffered from peptic duodenal ulcer during 7 years with frequent
attacks. Objectively: hypostenic physique, skin is pale, dry, flabby, going into folds. Hvosteck
symptom is positive. In the lungs, breathing is weakened in the lower parts, pathological noises are
not heard. BF is 19 per minute. Heart tones are rhythmic, muted. Pulse rate - 94 / min, blood
pressure - 100/75 mm Hg. The tongue is covered with a gray layer, dry. The abdomen is soft,
symmetrical, participates in the act of breathing, moderately painful in the epigastrium where the
“sound of splashing” is determined. Liver and spleen are normal. Symptoms of peritoneal irritation
are negative. Pasternatsky's symptom is negative on both sides. Gastric lavage was performed on an
empty stomach. 1500 ml of stagnant gastric contents with snippets of food were aspirated. Fecal
analysis - Gregersen's reaction is negative.
1. Diagnosis of pyloroduodenal stenosis, stage of subcompensation

2. Diagnostic methods
-Laboratory examination methods
Complete blood count - signs of dehydration, there may be a decrease
Hemoglobin level and increased ESR;
Biochemical blood test (bilirubin, total protein, sugar, potassium,
Sodium, calcium, chlorine, creatinine, urea, amylase,
AsAT, AlAT, alkaline phosphatase)
Hypokalemia, hypochloremia, hypoproteinemia are observed,
Increased creatinine, urea nitrogen; in the study of pH and gases
Blood ascertain metabolic alkalosis, which changes by a decrease
pH coagulogram; general clinical analysis of urine (hematuria,
albuminuria, cylindruria).
- During X-ray examination In the stage of subcompensation, the stomach is expanded, on an
empty stomach
contains
Liquid, its peristalsis is weakened, pyloroduodenal area
Narrowed. After 12:00, the remnants of the contrast are found in the stomach
Substances after 24 hours are completely evacuated from the stomach.
Endoscopic fibrogastroduodenoscopy (EFGDS)
At endoscopic examination, determine the degree of narrowing
Pyloroduodenal zone, determine the condition of the mucous membrane and size
The stomach, there is also the opportunity to conduct a biopsy for histological
Verification of the diagnosis.
With subcompensated stenosis, the stomach is enlarged, the pyloroduodenal canal is narrowed
to 0.5-0.8 cm
Due to severe cicatricial deformity, peristaltic activity
Lowered.
Ultrasonography (USG) and computed tomography (CT)
With subcompensated stenosis sonographically
An empty stomach is visualized, an enlarged stomach that contains fluid, sometimes with
An admixture of a small amount of food debris. Muscle layer of the wall
The stomach thickens to 3-5 mm (normal 1-2 mm).
3.Likuvannya
Patients with exacerbation of peptic ulcer conduct a course
Intensive conservative antiulcer treatment over
2-3 weeks.
-In the preoperative period carry out infusion therapy of water-electrolyte metabolism with
the introduction of complex saline solutions, albumin, blood plasma.
The complex of infusions include:
1. Hemodynamic, which include low molecular weight dextrans (reopoliglyukin),
medium molecular dextrans (polyglucin) and gelatin preparations (gelatin).
Increase bcc, increase blood pressure, improve microcirculation.
2. Detoxification (neogemodez, polydez, neocompensated).
3. Preparations for parenteral nutrition: protein (casein hydrolyzate, aminopeptide,
nitrolysin), amino acid (polyamine, infezol, freeamine), fat (lipofundin,
librolipid) and hydrocarbon (glucose, sorbitol, fructose).
4. Regulators of the water-salt and acid-base conditions: saline solutions (solution
sodium chloride, Ringer-Locke solution, disol, trisol) and osmodiuretics (mannitol,
sorbitol).
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5. Drugs with the function of oxygen transfer (perfluorane, foliosol) - bind (2-3 times
better than Hb) and transport oxygen.
6. Preparations of complex action (polyphore, reogluman, lactoprotein, rheosorbylact).
- These patients are given full antiulcer treatment -
Triple therapy aimed at eradicating Helicobacter pylori infection
And a decrease in acidity. (Clarithromycin 500 mg 2 r / d, amoxicillin 1000 mg 2 r / d, omez
20 mg 2r
/ d)
- Systematic decompression of the stomach - gastric lavage and gastric aspiration
Content through the probe.
An effective treatment is enteral nutrition (probe
Or through eunostomom).
- In case of subcompensated stenosis, if contractile
The ability of the muscles of the stomach, perform vagotomy with surgery, drains
Stomach. With drainage operations, pyloroplasty is used,
Duodenoplasty and gastroenteroanastomosis, if pyloroduodenal
The area expressed is scarred altered.
Clinical task 51 The 51-year-old patient was hospitalized with complaints of general weakness,
dizziness, weight loss, moderate abdominal pain, and abdominal distension. From the anamnesis it is
known that the patient was repeatedly treated in a drug dispensary for alcoholic delirium. 2 months
ago he was treated for gastrointestinal bleeding. Objectively: general condition is of moderate
severity, paleness and moderate yellowing of the skin and mucous membranes, vascular asterisks on
the skin are present. Pulse rate is 89 beats / min. BP is 135/90 mm Hg. The tongue is dry with a
brown layer. The abdomen is enlarged, flattened. The venous mesh is clearly contoured on the
anterior abdominal wall. The liver protrudes from the costal arch by 5 cm, dense, with a pointed
edge. The spleen is palpated, by percussion - 12 × 8 cm. In the vertical position, percussion is
determined the blunting sound lower the navel level.
Diagnosis: cirrhosis of the liver of alcoholic etiology, with moderate activity,

subcompensated . Progressive portal hypertension III art (ascites, varicose veins
expansion of the veins of the esophagus and stomach, expansion of the veins of the anterior
abdominal wall in the form
“Jellyfish heads”, splenomegaly)
laboratory criteria
anemia (a decrease in the number of red blood cells and a decrease in hemoglobin)
-decrease in the number of leukocytes, platelets) fibrinogen prothrombin time or index
reduced.
-hypoproteinemia (hypoalbuminemia) and hyperglobulinemia
- AlAT, AsAT increased 1.5-2 times
- Sulemov test, reduced to 1.2-1.8 ml
-Thymol test, increased to 8-9od
- Direct bilirubin level, 34-50mg / l
increase in alkaline phosphatase
- increased Ig A, C, M, hypernatremia
Ultrasound scan:
● liver enlargement of varying degrees, the presence of irregularities in the contour of the
ventral surface
liver, capsule compaction, wide band of high echogenicity; in the parenchyma
dense ribbon-like structures are determined;
● gross violations on the part of blood vessels (decreased blood supply to blood vessels, as a
result of which
the veins differ little from the surrounding tissue, small vessels are not detected, an increase
the diameter of the portal vein is more than 15 mm, and the splenic vein is more than 10
mm; recanalization
umbilical veins, spontaneous vascular shunts)
● late formed enlarged spleen;
● echolocation allows you to diagnose the accumulation of ascitic fluid first around
liver, and then in the lateral abdomen and in the pelvis.
● Signs of portal hypertension: portal vein expansion> 15 mm with single-phase or
the reverse direction of blood circulation and the presence of collateral circulation,
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especially in the left gastric, splenic and umbilical veins, and splenomegaly (symptom
weakly specific)
Endoscopic examination: esophagogastroduodenoscopy is performed routinely with the aim
of
Diagnosis of varicose veins of the esophagus and stomach, portal gastropathy or ulcers.
Histological examination of a liver biopsy of centrolobular hyaline (body) clusters
Mallory), a neutrophilic reaction around hepatocytes, a large wedge obesity of hepatocytes,
relative preservation of portal tracts, pericellular fibrosis
treatment
1. Complete Quitting Alcohol Low-Fat Diet
treatment of protein-calorie malnutrition (35-40 kcal / kg / day, protein 1.2-1.5 g / kg / day)
and
food deficiencies associated with alcohol abuse, most often: vitamins A, D,
thiamine , folic acid andpyridoxine and zinc.
2. The maximum dose of prednisone (20-30 mg / day) for 3-4 weeks to reduce the level
bilirubin and aminotransferase activity doubled.
3. Pyridoxalphosphate (coenzyme of vitamin B) 2 tablets (20 mg) 3 times a day or 10
mg 1-3 times a day for 1 month.
4. Tocopherol acetate (vitamin E), 1 capsule (0.2 ml of a 50% solution) for 1 month or 1-2
ml of 10% solution in / m 2 weeks
5. Lipoic acid 600 mg in the morning for a month.
6. Enzyme preparations (pancreatin, preparations containing amylase, protease, lipase,
A combination preparation containing amino acids
7. The combined preparation containing sodium chloride, potassium chloride, calcium
chloride,
sodium bicarbonate, povidone, magnesium chloride, 400 ml each + 500 ml 5% glucose
solution
+ 100 mg iv carboxylase for 10 days.
8. Correction of hypoalbuminemia is necessary - albumin in 100 ml of a 20% solution (5-6
infusions)
or freshly frozen plasma of 150 ml (4-5 infusions)
9. Ursodeoxycholic acid 12-15 mg / kg / day for 6 months (characterized
cytoprotective and choleretic effect, reduces bile acid deficiency in
intestines).
10. Spironolactone or eplerenone 50-100 mg 2 times a day. With severe ascites, the dose
increase every 2-3 days by 50-100 mg to a maximum of 400 mg / day (12-16 tablets).
In the absence of a positive diuretic effect, 100-200 mg are prescribed
spironolactone per day and 20-160 mg of furosemide (1 time per day in the morning 2 times a
week under
control of diuresis and electrolyte composition of the blood) or 20-40 mg of torasemide.
Positive diuresis should not exceed 500 ml / day. With refractory ascites -
paracentesis.
11. Decrease in portal pressure of propranolol in a dose of 10 mg 3 times a day) or nitrates
(isosorbide mononitrate, 30-60 mg / day), iv nitroglycerin drip in the form of 1% alcohol
solution at the rate of 1 ml (10 mg) in 400 ml of Ringer with a speed of 10-15 drops / min for
24-72 h (nitroglycerin is administered after stabilization of blood pressure).
12. Lactulose 60 ml / day iv continuously;
13. endoscopic sclerotherapy of varicose veins of the esophagus and stomach
Clinical task 52 The patient, 81 years old, complained of severe abdominal pain. The pain started
suddenly after eating, gradually intensified. He suffers from atrial fibrillation, 5 months ago got an
acute myocardial infarction. The condition is serious. Skin is pale with acrocyanosis. Pulse rate is 110
in 1 minute, blood pressure - 90/60 mm Hg. The abdomen is swollen, soft, and painful on deep
palpation. Percussion - high timpanists. Peristalsis is sharply reduced, single waves. Per rectum -
remains of feces with mucus and blood.
Diagnosis: Acute intestinal obstruction
X-ray examination - the main special method for the diagnosis of OKN, using
which you can identify the following symptoms: 1. Kloiber bowl - horizontal level
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liquid with a dome-shaped enlightenment above it, which has the appearance of an inverted
bowl. At
strangulation obstruction may occur within an hour, with obstructive obstruction - in 3-5
hours from the time of illness. Liquid levels (small and large intestine) localized in the left
hypochondrium, indicate high obstruction. At small intestinal levels, vertical
dimensions prevail over horizontal, existing lunate folds of the mucous membrane; at
large intestine horizontal dimensions prevail over vertical, determined by haustration.
2. Intestinal arcades appear when the small intestine is inflated with gases, while in the lower
knees arcades available horizontal fluid levels. 3. Cirrus symptom occurs
with high intestinal obstruction and is associated with stretching of the jejunum, which has
high
circular folds of the mucosa. Ultrasound signs of intestinal obstruction: • expansion
intestinal lumen> 2 cm with the phenomenon of "fluid sequestration"; • thickening of the wall
of the small intestine> 4
mm; • the presence of reciprocating movement of the chyme along the intestine; • increase in
fold height
mucous membrane> 5 mm; • increase in the distance between folds> 5 mm; • intestinal
hyperpneumatization
in the drive part with dynamic intestinal obstruction - the absence of reciprocating
translational movement of the chyme along the intestine; the phenomenon of fluid
sequestration into the intestinal lumen; • not
pronounced relief of the folds of the mucosa; • intestinal hyperpneumatization in all
departments
Valya St. - asymmetry of the abdomen, tumor formation may appear on palpation
(swollen loop) and tympanite with percussion above it.
SM Sklyarova - the noise of a “splash” of fluid over the loops of the intestine.
S. Shiman - when the sigmoid colon is rotated, bloating is localized closer to the right
hypochondrium,
whereas in the left iliac region, abdominal retraction is noted.
St. Spasokukotsky-Wilms - “the noise of a falling drop”
S. Kivulya - amplification of a tympanic sound with a metallic tint over an extended bowel
loop.
treatment:
conservative therapy
1. Impact on the autonomic nervous system - bilateral perirenal procaine
blockade.
2. Decompression of the gastrointestinal tract (GIT) by aspiration of contents through
nasogastric tube and siphon enema.
3. Correction of water-electrolyte disorders, detoxification, antispasmodic therapy,
treatment of enteric insufficiency.
4. Ringer-Locke solution, solutions of potassium, glucose with insulin, solutions of albumin,
protein,
plasma amino acids. In the presence of metabolic acidosis, sodium bicarbonate solution is
prescribed.
To improve microcirculation, reopoliglyukin with compliance and trental is
prescribed. Criterion
adequate infusion therapy is the normalization of circulating blood volume, indicators
hematocrit, central venous pressure, increased diuresis. Hourly diuresis should be
not less than 40 ml / h.
5. The release of a significant amount of gas and feces, the cessation of pain and improvement
the patient after conservative measures indicates effectiveness
conducted drug therapy. If conservative treatment does not give effect within 3:00,
the patient must be operated on.
surgical treatment
After performing laparotomy, the abdominal cavity is revised, before which
It is recommended to make novocaine blockade of the mesentery of the small and large
intestines. Special attention
turn to “typical” places: angular segments (hepatic and splenic corners of the colon
intestines), places of occurrence of internal hernias (internal inguinal and femoral rings, neck
hole, a bunch of Traits, Winslov hole and aperture hole).
The methods for determining intestinal viability are universal: after warming the intestine
with napkins,
dipped in warm isotonic sodium chloride solution for 10-15 minutes, and also after
introducing 20-40 ml of a warm 0.25% solution of novocaine into the mesentery of the pink
serous membrane
color, brilliant, peristalsis of this area is preserved, vascular pulsation is determined
mesentery.
Bowel resection for obstruction is carried out according to universal principles: 1. Allocate
30-40 cm above the place of the obstacle, i.e. the drive section (usually inflated by gases), and
15-20 cm below, that is, in the abduction department. 2. Perform an anastomosis "side by
side" or "end to end"
(the latter type is used only with minor differences in the diameter of the drive and outlet
parts of the intestine, in the absence of decompensated obstruction). 3. In high probability
anastomotic suture failure it is advisable to perform an operation such as Maidl (even if
restoration of intestinal obstruction is possible). 4. If for some reason the overlay
primary anastomosis is impossible, it is necessary to bring and divert sections of the intestine
with
the formation of stoma pits on the anterior abdominal wall. The exception is operations on
the sigmoid colon, when the designated section of the intestine is sutured tightly and
immersed in the abdominal
cavity - obstructive resection of the Hartmann type. Postoperative Treatment: Recovery
BCC, correction of electrolyte and protein composition of blood for the treatment of
endotoxemia, including
mandatory antibiotic therapy; restoration of motor, secretory and suction
bowel functions, that is, treatment of enteric insufficiency.
Clinical task 53 A 74-year-old patient complains of a protrusion above the navel. A year ago, a
laparoscopic cholecystectomy had been performed for chronic calculous cholecystitis. After the
operation she added 15 kg in here weigh. Pulse rate is 88 beats / min., arrhythmic. BP - 175/100 mm
Hg. On the skin along the midline above the navel a linear scar up to 50 mm is present. When she is
staying, a protrusion 60 * 50 mm appears. In the laying position, the formation disappears.
Diagnosis: postoperative (ventral) deft hernia along the white line of the abdomen.
Diagnosis: palpation - a tumor that can be seen visually,
palpation of the hernial sac and hernia ring is palpable, dexterous in horizontal
position exercises in the abdominal cavity.
1. Radiography using contrast materials. During the study into the cavity
contrast enhancers are introduced into the stomach, after which the contours of the organ are
visible in the picture. Purpose of this
research - examine whether a part of the stomach has dropped out in a hernial sac.
2. Gastroduodenoscopy . The study will provide information on the condition of the stomach
and its mucous membranes.
Gastroduodenoscopy also determines the involvement of the stomach in the pathological
process.
3. Ultrasound diagnosis, you can assess the condition of the abdominal organs and study
involvement in the hernia process.
4. Computer and magnetic resonance imaging .
treatment:
promptly:
1. Tension plastic - opening a hernia, after which the white line of the peritoneum is charged
with sutures,
strengthens their walls. This plastic has its drawbacks: large cut, large
likelihood of repeated bulging.
2. Tension-free plastic. To strengthen use a polypropylene mesh, less
the likelihood of relapse than a stretch.
3. Laparoscopy of a hernia of the white line of the abdomen . Three punctures, through which
a hernia is removed. After
surgery imposes mesh tissue. Laparoscopic surgery has several advantages:
low probability of relapse, absence of large scars, short recovery periods
period.
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4. Peritoneal surgery . During this operation, three punctures are also made through which
introduce a balloon, which is inflated. So, a small space is formed, which gives
the ability to access the protrusion and remove it.
Postoperative:
Diet, drinking regimen, antibiotic therapy (amoxiclav 500 mg 2 rd 5 days), bandage, exercise
therapy, pool
Clinical task 54 The 62-year-old patient underwent surgery for acute gangrenous calculous
cholecystitis. Technically difficult laparoscopic cholecystectomy was performed, surgeons found a
pronounced inflammatory infiltration in the projection of the Kahlo triangle. In the p / o period the
patient's condition became worth. On the 2nd day, moderate scleral jaundice appeared. On the 3rd
day, the leakage of bile through drainage tube started, 100 ml a day amount. The tongue is coated,
dry. The abdominal wall is soft, not bloated, takes part in the act of breathing. On palpation, the
moderately painful in the right hypochondrium is detected. Symptoms of peritoneal irritation are
negative.
1) Diagnosis - postcholecystectomy syndrome, iatrogenic biliary damage
pathways (or general hepatic strait or leakage of the stump of the cystic duct)
● Ultrasound (detection of accumulation of bile in the bed of the removed gallbladder)
● Endoscopic retrograde pancreatocholangiography (condition assessment
bile duct, stenosis of the large duodenal papilla)
● Magnetic resonance cholangiopancreatography (non-invasive method, condition assessment
bile ducts)
3) Tactics and treatment
● Through drainage of the subhepatic space - rinsing with antiseptic solutions with
active aspiration of secretion, antibacterial and detoxification therapy. (When
the absence of organic lesions of the biliary tract and since there is no clinic
biliary peritonitis)
● If organic lesions of the bile ducts are detected, patients are shown repeated
operation. The nature of the operation depends on the specific cause.
postcholecystectomy syndrome. With a long cult of the cystic duct or
leaving a part of the gallbladder make their resection (laparoscopic removal
residual stump of the gallbladder or ducts), with choledocholithiasis
(laparoscopic choledocholithotomy + external drainage of the common bile duct) and stenosis
large duodenal papilla (endoscopic papillosphonterterotomy). At
long post-traumatic extrahepatic biliary tract strictures
the imposition of bilidegative anastomoses with the duodenum or jejunum.
● Preparations of ursodeoxycholic acid - ursofalk, henofalk
● Antibiotic therapy + prebiotics
● Antispasmodics - shpa, Duspatalin
● Enzyme preparations - creon, mezim
● Hepatoprotector-essentials, hepatogenesis
Clinical task 55 An 18-year-old teenager fell on the wheel of his bicycle with his left hypochondrium.
There was а pain in the area of trauma. The local pain later spread to the lower abdomen with
irradiation to the left supraclavicular area, which caused difficulty breathing. The general weakness
grew. The general condition is severe, covered with sticky sweat. A teenager cannot lie down due to
increased pain in the supraclavicular area. Pulse rate is 115 beats / min., rhythmic. BP - 100/60 mm
Hg. The tongue is dry, covered with white plaque. The abdomen is soft on palpation. Slight muscle
tension is detected on the left. The Blumberg symptom is weakly positive. Percussion demonstrated
a blunting in the lateral parts of the abdomen.
1) Diagnosis - post-traumatic rupture of the spleen

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● OAC (decreased hemoglobin, hematocrit, decreased red blood cell count,
slight leukocytosis, elevated ESR).
● Ultrasound (presence of free fluid in the abdominal cavity, echo-negative shadows around
spleen, an increase in the size of the spleen and the fuzziness of its contours, the presence of a
gap and
determine the degree of damage)
● X-ray and scopy of OBP (the shadow of the organ is enlarged, the area under the diaphragm
on the left and
the lateral canal in the iliac region is darkened, the left dome of the diaphragm is raised and
limited to movable)
● CT (defects in the capsule / organ parenchyma, hemoperitoneum size)
● Angiography (extravasation of X-ray liquid, damaged vessels)
● Laparocentesis (detection of blood in the abdominal cavity)
● Laparoscopy (size of hemoperitoneum, localization and degree of spleen injury)
symptoms:
● phrenicus symptom (or Eleker - blood irritates the peritoneum of the left subphrenic
space and phrenic nerve - irradiation to the left supraclavicular region, not
can take a deep breath)
● Rozanova or Vanka stand up (when you try to lie down immediately rises, the blood
irritates a large
surface of the peritoneum)
● de Kervena (blunted percussion sound along the left side channel)
● galansa (a symptom of fluid movement is in the right half of the abdomen)
● Shchetkin Blumberg symptom (after tidying up the fingers, the pain intensifies)
● Kulenkampfa (stomach painful but soft)
3) Tactics, treatment
Hemostatic therapy (dicinone 2-4 ml cc, 10 ml 10% calcium gluconate),
normalization of rheological vl blood (reopoliglyukin 3-10 mg / kg), correction of CBS
(bicarbonate solution 4% 200-300 ml), prednisone 5-8 mg / kg.,
antibiotic prophylaxis.
Compensation of blood loss (up to 10% bcc - up to 500 ml) -Auto compensation mechanism
up to 15%
BCC - up to 750 ml - up to 2 l)
Immediate surgery - median laparotomy (remove blood
electric suction, specify the source of bleeding and the size of the damage for
definitions of further methodology)
● Rupture of the parenchyma of the spleen, numerous ruptures of the organ, its contrition -
splenectomy (gold standard)
● Separate capsule ruptures and shallow cracks - are sutured with catgut sutures,
tamponade wound oil seal.
The operation is completed by drainage of the abdominal cavity.
Postoperative period: infusion therapy, antibiotic therapy,
painkillers
Clinical task 56 A 72-year-old woman was admitted to the surgical department with complaints of
cramp-like abdominal pain, which appeared suddenly 5 hours ago, repeated vomiting. She has been
suffering from chronic calculous cholecystitis about 20 years. She refused surgical treatment. Pulse
88 beats / min., Arrhythmic. АТ - 160/90 mm Hg. Moderately symmetrical bloating of abdominal wall,
increased peristaltic noises, weak «sound of splashing" are objectively determined. Per rectum –
fecal masses of normal color
Diagnosis: Intestinal obstruction obstruction (possibly due to gallstone obstruction)

Diagnosis: X-ray of OBP, intestinal hyperpneumosis, Symptom of Kloiber bowls, thin and
colonic arches, with small bowel obstruction, a casey symptom.
Ultrasound scan for determining pathological lesions, effusion ...
Complete blood count - signs of inflammation
Urinalysis - signs of inflammation
Treatment: you can try to conservatively launch proliferation by administering drugs K,
proserin, IR, hypertensive enema. If ineffective, surgical treatment is indicated in
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urgent order.
Preoperative preparation - 1.5-2 l / in crystalloid regions, drain from the stomach, Lavage
rectum. In the case of decompensated intestinal obstruction with significant
the expansion of the intestinal loops, it becomes impossible to impose a primary anastomosis,
shown polyative colostomy (Considering the age of the patient, this is generally a shit). If
confirmed cholelithiasis does not pass enterotomy, remove the stone and sutured
Clinical task 57
The 34-year-old woman was hospitalized in the surgical department with complaints of heaviness in
the epigastric region, general weakness, dizziness after eating sweet or milk foods. About 7 months
ago she underwent surgery for duodenal peptic ulcer complicated by decompensated stenosis. A
distal partial (2/3 parts) gastrectomy was performed by Billroth II procedure. After the operation she
lost 5 kg of weight. The condition is relatively satisfactory. Pulse rate is 78 beats / min., rhythmic. BP -
115/60 mm Hg. The abdomen is soft and painless. Symptoms of peritoneal irritation are negative.
Diagnosis: moderate dumping syndrome

Diagnosis:, dumping test - measurement of blood pressure and heart rate before and after
eating, with FGS - large
diameter of gastroenteroanastomosis. It usually has a rounded shape (in N - slit-like).
exchange of Na +, K +, Cl-, Ca2 +, anemia, a sharp decrease in CVP, X-ray examination
stomach with barium contrast - enhanced (wide stream in 5-15 minutes) barium evacuation
through
anastomosis, expansion of the abduction loop and rapid advancement of the contrast medium
in
distal small intestine. Treatment: 1-2 tbsp. - conservatively 3 tbsp. - surgical treatment
(gastroeunoduodenostomy) Conservative therapy 1) Diet therapy: meals 6 times a day
in small portions. Separate consumption of liquid and solid foods. First - the second course,
through
30 minutes is the first. The food should NOT be hot (so as not to speed up the
evacuation). Recommended for
30 minutes before a meal - a glass of tomato juice to excite the hydrokinetic phase of
secretion
(pancreatic juice). Reduce the amount of carbohydrates, replace sugar with sorbitol. Limit oily
food. After eating, go to bed for 30 minutes. 2) restorative therapy
- glucose with insulin
- Vitamin B1 6% - 1 ml;
- vitamin B12 at 2000 mcg / day;
- Vitamin B6 5% - 1 ml;
- Nicotinic acid 1% - ml.
- transfusion of plasma, albumin, red blood cells, plasma substitutes (HES, osmotically active
solutions).
3) Substitution therapy: natural gastric juice before or during meals (1 tablespoon
1/3 cup of water), enzymes - pepsin, pancreatin, panzinorm, creon.
4) Sedative therapy: elenium, relanium, seduxen, trioxazine, chlorpromazine, barbiturates
5) Slow motility of the duodenum 12 30 minutes before a meal - 0.5 ml. 0.1% solution
atropine subcutaneously
6) In case of cachexia - corticosteroids, anabolic steroids
Surgery
Indications for surgery: severe dumping syndrome in case of treatment failure
nutrition and long-term comprehensive drug treatment.
Surgical intervention consists of a reduction with gastroejunoduodenoplasty.
Intestinal transplant slows down gastric stump emptying, inclusion
the duodenum improves digestion and in some patients it can reduce
the intensity of the dumping reaction
Clinical task 58
Patient S., 39 years old, went to the family doctor with complaints of abdominal pain, which worsens
after exercise. Periodic vomiting, which brings relief at the height of pain. During the last year,
frequent bloating and grunting in the abdomen, especially after eating dairy foods and fruits. From
the anamnesis: 1 year ago she underwent surgery for an abdominal injury a ruptured intestine and
intraperitoneal bleeding. Objectively: the skin is the mucous membranes have a body color; the
tongue is moist, covered with white layers. Pulse rate is 78 beats / min., rhythmic. BP - 130/80 mm
Hg. The abdomen is deformed due to p / o scars after the middle - middle laparotomy and
contrapertures. Auscultatory - hyperperistalsis. Deep Palpation palpation is painful, especially in the
area of p / o scars, determined by the rumbling of the intestine. Positive symptoms of Blinov. Leott,
Knoh, Carnot, Hunafin. Pasternatsky's symptom is negative, urination without features. Defecation -
a tendency to constipation. Per rectum - the walls are normal, not painful, on the glove traces of
formed brown feces.
Diagnosis: Adhesive disease of the abdominal cavity, partial adhesive intestinal obstruction
Help with examinations and symptoms: complaints are typical, can occur in many diseases,
suggest possible obstruction - vomiting, which brings relief, bloating and grunts
after eating milk and fruits. Also surgery for abdominal injury + deformity
abdomen through surgery + symptoms of Blinov, Leott, Knoch, Carnot, Hunafina - are
signs of peritoneal commissural disease. Given the normal condition of the patient + traces
formed stool can be suspected that the obstruction is partial.
Tactics and treatments: treatment is ambiguous, relapse-free treatment of adhesive disease, in
principle,
does not exist. Tactics with the patient - at first conservative, this is symptomatic therapy,
according to
to a greater extent - antispasmodics (no-shpa, papaverine), analgesics (analgin, baralgin,
spasmalgon),
non-steroidal anti-inflammatory (Revmoxicam, Naklofen), drugs that affect motility
GIT (proserin, cerucal), antihistamines (diphenhydramine, suprastin), biogenic stimulants
(aloe,
plasmol, vitreous body), probiotics (linex, Enterogermina), vitamins (aevit, vit. s),
electrophoresis with novocaine, lidase, potassium iodide, magnetotherapy, paraffin baths on
anterior abdominal wall, fractional nutrition, excluding foods that are high in fiber, food
which irritates the intestinal mucosa and has an allergenic effect and is included in the diet
prebiotics. At the first manifestations of a violation of the passage through the intestines, they
washed
stomach and a cleansing or siphon enema, with an increase in intestinal symptoms
obstruction - surgical operation opening of adhesions, adhesolysis, etc
Clinical task 59 Patient L., 65 years old, became acutely ill 10 hours ago when he got pain in the left
half of his abdomen, first constant and then cramp – like. Subsequently, vomiting joined, which did
not bring relief. Relatives and the patient considered it food poisoning, washed his stomach and took
laxative pills. After 2 hours the pain intensified. Again there was vomiting with an unpleasant odor in
the form of "liquid feces". The general condition of the patient is severe, conscious, asks to drink but
a sip of water causes repeated vomiting. Pulse rate is 140 beats / min., Weak filling and tension. BP -
90/60 mm Hg. The skin is pale with an earthy tinge, dry, turgor and elasticity are reduced. His eyes lit
up a little. The tongue is dry, "like a brush". The abdomen is swollen, asymmetrical, the right halves
protrude forward and sideways. In the area of the right hypochondrium, the formation of 12 * 10 cm
is palpable, dense, immobile, painful. At auscultation: peristalsis is sharply weakened, a positive
symptom of Spasokukotsky. The expressed symptom of Sklyarov. Per rectum - rectal ampoule dilated
and empty
Diagnosis: Acute small bowel obstruction.

Help with examinations and symptoms: cramping pains, fecal vomiting (= transiently
unfavorable criterion), serious condition, pale skin with an earthy tint, sunken
skin elasticity is reduced (Hippocrates face), swollen asymmetric abdomen, palpation
painful formations, weakening of peristalsis, + cm Spassokukotsky, + Sklyarov + per
rectum - these are all signs of the late stage of the second phase of GKN (that is, the transition
from the stage of intoxication
(Stage 2 GKN) in the stage of diffuse peritonitis (stage 3 - terminal).
Tactics and treatment: Surgery.
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2020/5/21
2 At any localization, access is median laparotomy.
3 Operations with OKN provide for the gradual solution of the following tasks:
● establishing the cause and level of obstruction;
● before manipulation with the intestine, it is mandatory to conduct a novocainal mesenteric
blockade
(if there is no oncological pathology);
● elimination of the morphological substrate of GKN;
● determination of the viability of the intestine in the zone of the obstacle to determine the
indications for it
resection;
● establishing the boundaries of the resection of the changed intestine and its
implementation;
● establishing indications for the draining of the intestinal tube and the choice of drainage
method;
● sanitation and drainage of the abdominal cavity in the presence of peritonitis.
4 Identification of the obstruction zone immediately after laparotomy does not relieve
the need for a systematic revision of the state of the small intestine throughout its duration, as
well as
and colon. Revision is preceded by mandatory infiltration of the mesentery root with a
solution
local anesthetic. In the case of severe overflow of intestinal loops before
revision decompression of the intestine using gastrojejunal probe.
5 Obstruction is performed in the least traumatic way with clear
determination of specific indications for the use of various methods: dissection
multiple adhesions; resection of the changed intestine; elimination of inversion,
intussusception,
nodal ablation or resection of these formations without prior manipulations on the altered
gut.
In determining the indications for bowel resection, visual signs are used (color, edema
walls, subserous hemorrhages, peristalsis, pulsation and blood supply of parietal
vessels), as well as the dynamics of these signs after the introduction of a warm solution into
the mesentery of the intestine
local anesthetic.
When recognizing the non-viability of the intestine, a section is resected and an anastomosis
is applied
end-to-end type (as a rule, less often - end-to-side)
Clinical task 60 A 68-year-old man got abdominal pain two days ago, which increased and became
cramp – like. The patient associates the pain with fatty fried foods eating. In the last 6 hours 2 times
there was vomiting with greenish - brown liquid and 2 times defecation with mucus. From the
anamnesis: during the last 5 months worried about general weakness, fatigue, sweating at night, lost
up to 8 kg of weight. At the time of examination: the skin is pale. Body T - 37.2oC. Pulse rate is 92
beats / min. BP - 120/60 mm Hg. The tongue is densely covered with a gray layer, dry. The abdomen
is evenly swollen but soft. Moderately painful in the right half. Intestinal motility is enhanced,
sonorous. In the right iliac region, the formation of 80 * 70 mm, moderately mobile and painful is
palpated. Positive symptom of Sklyarov. Shchetkin-Blumbler's symptom is negative. Per rectum -
intestinal mucus on the glove.
Diagnosis: cancer of the cecum of stage 3, obstructive GKN little information, but in
accordance with
sizes, most likely, this is stage 3).
Help examinations and symptoms: for 5 months, general weakness, fatigue,
sweating at night, 8kg weight loss, pale skin, moderately mobile and painful formation in
right zdvuhvinniy plot - a sign of a tumor of the cecum; cramping pain, worse
general condition, a swollen abdomen, increased peristalsis, + cm Sklyarova - signs of OKN.
Tactics and treatment: surgical treatment + adjuvant chemotherapy (oxaliplatin,
fluorouracil, cetuximab, etc.).
Operative - right-sided hemicolectomy.
THORACIC SURGERY II STATION
Task № 1
Patient 53 complains of coughing with purulent sputum up to 200 ml/day, expiratory choking when
walking, periodically increasing body temperature to 37.2–37.4 °С. He is sick for many years.
Objectively: acrocyanosis, a chest-shaped barrel-shaped, nails resemble watch glasses in shape.
Percussion over the light boxed sound. During auscultation, vesicular breathing, scattered dry rales,
in the lower parts of the right lung, large-bubbly moist rales. In the general analysis of blood: white
blood cells 8.2×109 /l, ESR 15 mm / hour. During X-ray examination, the lungs are emphysematous,
the pulmonary pattern in the lower sections is similar to a honeycomb, is deformed.
1) what is the diagnosis?

Bronchiectatic disease, severe course, stage of exacerbation, bronchiectasis in the lower
sections
right lung, complications of emphysema.
2) examination methods need to be appointed in addition?
2. Chest x-ray in 2 projections,
3. ECG
4. general blood and urine tests,
5. Biochemical blood test (coagulogram, protein fractions),
6. Spirography, pneumotachometry,
7. FBS
8. General sputum analysis
9. Sputum analysis for mycobacteria
10. If necessary, special radiological techniques (SKT, SKT with iv
contrasting)
11. computed tomography
12. Bacteriological examination of biological substrates (sputum, punctate, leaching
water, etc.)
13. Bacterioscopic examination of biological substrates,
14. Cytological examination of biological substrates.
15. Serial angiopulmonography makes it possible to see anatomical changes in blood vessels
lungs.
3) maybe a CT scan?
Computed tomography is the main diagnostic method for BE. Possible signs of EB: internal
the diameter of the peripheral bronchus is 2 times the diameter of the previous pulmonary line
(symptom of "ring") - cylindrical type of BE; there is no narrowing of the lumen of the
bronchus to the periphery
(symptom of "tram rail") - also a cylindrical type of BE; uneven lumen of the bronchi
with diverticulum protruding protrusions ("rosary") - varicose BE;,
4) indications and contraindications for surgical treatment.
Indications: pulmonary hemorrhage pneumothorax, is not eliminated by drainage; frequent
exacerbations of the process, not amenable to conservative treatment; inability to achieve
persistent
remission for 2–3 years of cirrhosis of the zone of the lungs with a purulent process in sharply
expanded bronchi.
Contraindications to the operation are: • COPD, expressed by LN and NK (HLC) •
Amyloidosis
kidney failure.
5) possible complications of the course of their prevention?
Complications: pulmonary hemorrhage; bronchial obstructive syndrome, pulmonary failure,
chronic pulmonary heart, pleural cavity pathology (spontaneous pneumothorax, empyema
pleura); pathology of lung tissue (abscess and gangrene, cirrhosis) sepsis extrapulmonary
processes (ulcer
stomach and duodenum, amyloidosis) . Prevention timely treatment,
vaccination against influenza and Streptococcus pneumoniae, combined vaccines
(bronchomunal, ribomunil), elimination of the focus of infection.
Task № 2
A 38-year-old patient was hospitalized with complaints of cough with purulent sputum (up to 60–80
ml per day), an increase in body temperature up to 39 °C. He associate the disease with hypothermia.
Objectively: pulse 96 in 1 min, rhythmic. Blood pressure 110/60 mm RT. Art. Respiratory rate 30 in 1
min. On examination, a lag of the right half of the chest during breathing was found. Percussion
determines the local blunting of percussion sound at the angle of the right scapula, in this area moist
rales of various sizes, amphoric breathing are heard.
1) previous diagnosis?
Acute abscess of the lower lobe of the legal lungs.
- 1. Radiography of the chest cavity in 2 projections
- 2. General blood and urine tests
- 3. Analysis of sputum BA
- 4. Biochemical blood tests (coagulogram, protein fractions)
- 5. Spirography
- 6.Pneumotachometry
- 7.ECG
- 8. FBS
- If necessary -
- 9.SKT OGK (spiral computed tomography)
- 10. Bacteriological studies of biological substrates (sputum, punctate,
wash water, etc.)
- 11. Bacterioscopic studies of biological substrates
- 12. Cytological studies of biological substrates
3) do you need bronchoscopy?
Bronchoscopy is an important method for the diagnosis and treatment of abscess legen.
the introduction of a bronchoscope bronchus causes convulsive compression of the lungs, as a
result of this with a cough
the abscess is emptied, pus is excreted through the bronchoscope.
bronchoscopy with active aspiration of pus from the bronchus, rinsing the cavity with
solutions
antiseptics, muco and fibrinolytics, which contribute to the dissolution and evacuation
necrotic substrate. For repeated (during the day) washing the abscess cavity
through the draining bronchus, prolonged endoscopic catheterization is used.
Indications for surgical treatment: 1. Multiple abscesses. 2. Gangrenous
abscess. 3. The diameter of the abscess cavity is more than 6 cm. 4. Lower lobe localization.
5.
bleeding II-III century; 6. Progress of the process against the background of active and
adequate therapy
7.Piopneumothorax stresses, cannot be eliminated by pleural drainage
cavities; 8. Not able to rule out suspicion of a malignant tumor.
Contraindications: decompensation of vital systems in terminal stages,
binary purulent destruction in the lungs, accompanying incurable malignant
tumors, amyloidosis of the kidneys.
5) possible complications of the course of their prevention
Complications - pleural empyema, pyopneumothorax, hemoptysis, pulmonary hemorrhage,
sepsis, bronchogenic dissemination, exudative pleurisy, phlegmon of the chest wall,
respiratory failure, asphyxiation with purulent masses. In the prevention of acute
effective treatment of acute pneumonia, especially
during the flu epidemic. Of great importance is the elimination of the focus of infection
Task № 3
On the 5th day after a cold, the patient developed a cough with a small amount of mucous sputum.
There was a single release of about 250 ml of purulent sputum with streaks of blood. The state of
moderate severity. Pulse 96 in 1 min, blood pressure 110/70 mm RT. Art. Respiratory rate 30 in 1
min. With auscultation over the left lung, vesicular breathing. Above the right lung, vesicular
breathing is weakened, moist rales of different sizes are heard above the lower part, and amphoric
breathing at the angle of the scapula
Acute abscess of the lower lobe of the legal lungs, moderate degree, stage of heat and
rejection
necrotic masses.
• UAC: leukocytosis, stab shift, toxic granularity of neutrophils, increased ESR. •
AAS: moderate albuminuria, cylindruria, microhematuria. • LHC: increase in non-specific
acute phase indicators: sialic acids, seromucoid, fibrin, α second γ - globulins. •
sputum analysis: purulent with an unpleasant odor, when standing, it is divided into three
layers: lower -
brittle sediment (pieces of lung tissue and Dietrich's crust), the middle layer is cloudy, liquid,
upper
layer - mucopurulent, foamy. Microscopy - white blood cells in large numbers,
elastic fibers, crystals of hematoidin, fatty acids. X-ray examination
OGK in two projections. In the diagnosis of cavity formation of the lungs, the leading role
belongs to
radiation research (radiography, fluoroscopy, tomography). ECG, bronchoscopy.
3) do you need bronchoscopy?
Bronchoscopy is an important method for the diagnosis and treatment of abscess legen.
the introduction of a bronchoscope bronchus causes convulsive compression of the lungs, as a
result of this with a cough
the abscess is emptied, pus is excreted through the bronchoscope.
with active aspiration of pus from the bronchus, washing the cavity with solutions of
antiseptics, muco- and
fibrinolytics, which contribute to the dissolution and evacuation of the necrotic substrate.
For repeated (during the day) washing the abscess cavity through the drainage bronchus
use prolonged endoscopic catheterization.
Indications for surgical treatment: 1. Multiple abscesses. 2. Gangrenous abscess. 3.
The diameter of the abscess cavity is more than 6 cm. 4. Lower lobe localization. 5.legenova
bleeding II-III
Art .;
6. progression of the process against the background of active and adequate therapy 7. stress
pyopneumothorax,
cannot be eliminated by drainage of the pleural cavity; 8.cannot exclude
suspected malignant tumor. Contraindications: decompensation of vital
systems in terminal stages, double purulent destruction of the lungs, concomitant
incurable malignant tumors, renal amyloidosis.
Complications - pleural empyema, pyopneumothorax, hemoptysis, pulmonary hemorrhage,
sepsis, bronchogenic dissemination, exudative pleurisy, phlegmon of the chest wall,
respiratory failure, asphyxiation with purulent masses. In the prevention of acute
effective treatment of acute pneumonia, especially
during the flu epidemic. Of great importance is the elimination of the focus of infection
Task № 4
In a 27-year-old patient, after an 8-day constant fever during a coughing attack, 200 ml of yellow
sputum flowed out. Objectively: body temperature 37.2 °C, respiratory rate 22 in 1 min, pulse 96 in 1
min, blood pressure 110/70 mm RT. Art. An X-ray examination of the chest in the left lung revealed a
round shadow with clear boundaries and enlightenment in the center
a) what is the diagnosis?

Acute abscess of the left lung, stage of abscess formation.
b) examination methods need to be appointed additionally?
acute phase indicators: sialic acids, seromucoid, fibrin, α second γ - globulins. •
sputum analysis: purulent with an unpleasant odor, when standing, it is divided into three
layers: lower -
brittle sediment (pieces of lung tissue and Dietrich's crust), the middle layer is cloudy, liquid,
upper
layer - mucopurulent, foamy. Microscopy - white blood cells in large numbers,
elastic fibers, crystals of hematoidin, fatty acids. X-ray examination
OGK in two projections. In the diagnosis of cavity formation of the lungs, the leading role
belongs to
radiation research (radiography, fluoroscopy, tomography). ECG, bronchoscopy.
c) The main directions of treatment.?.
● full evacuation of the contents of purulent cavities;
● effect on microorganisms located in the inflammatory focus;
● detoxification and correction of volemic disorders;
● restoration of impaired functions of vital organs and all types of metabolism
substances
● increased nonspecific resistance of the macroorganism;
● desensitization and regulation of the activity of the inflammatory process;
● symptomatic treatment of the most pronounced manifestations of the disease;
● elimination of complications.
Drug treatment: broad-spectrum antibiotics are prescribed that act bactericidal on
main groups of possible pathogens. Among the drugs of the penicillin group, such
amino properties (v / v ampicillin, v / m every 4-6 hours, 4-6 g / d, v / m amoxicillin, v / v)
1 g 2 r / d, with normal renal function - 2-12 g / s) and (iv azocin in 8 (4 times 2 g) -15 (3
times 5 g) g / d, the daily dose of penicillin is 6-12 g. It is advisable to use
dosage forms, which include beta-lactamase inhibitors (clavulanic acid,
sulbactam, tazobactam). The use of cephalosporins of the second gives good results.
(cefuroxime sodium 1.5 g 4 r / d or 3 g 3 r / d, cefamandole 0.5-1 g 4 r / d), the third
(cefotaxime 1-2
g 3-4 r / d, ceftriaxone 2-4 g 1 r / d, sometimes 1-2 g 2 r / d, cefadizime 1-2 g 2 r / d,
monotherapy
spend carbapenems (imipenem, meropenem), a daily dose of 2-4 g / day. Fluoroquinolones II
generation (ciprofloxacin, ofloxacin, lomefloxacin 200-400 mg / day), III generation
(levofloxacin, sparfloxacin 1000 mg / day), IV generation (moxifloxacin, gatifloxacin 1000
mg / day) is usually combined with metronidazole (ornidazole) or clindamycin (up to 1.8 g).
Detoxification therapy: - Glucose solution 5% 200-400 ml VVK 1-2 r / d - Sodium chloride
solution of 0.9% 200-400 ml of VVK 1-2 r / d - Ringer's lactate solution of 200-400 ml of
VVK 1 -2 g
Surgical treatment: Creating conditions for the natural outflow of purulent-necrotic masses
is to restore the drainage function of the bronchi. For this purpose, use:
fibrobronchoscopic sanitation lavage, repeated aspiration of sputum from nasobronchial
catheter, instillation of solutions of enzymes, antiseptics, broncho and mucolytics in the
endotracheal
microirrigator and aerosol inhalations with these agents.
Percutaneous drainage of pulmonary destruction is carried out mainly broadly
tube through a closed thoracoabsosthesostomy according to Monaldi. Interventions sometimes
complement
thoracoabcestoscopy with revision of purulent cavities and controlled removal of necrotic
sequestration. Further drainage is used for sanitation of abscesses with solutions
antimicrobial agents, as well as physical antiseptics. With acute purulent abscesses
small (less than 4 cm) sizes, the lack of sequestration may be sufficient
conduction catheterization for Seldinger or repeated puncture, pulmonectomy indicated
with progressive lung gangrene. passive drainage according to Bulau (Technique:
pleural cavity drainage is performed under local anesthesia most often in the axillary
areas in the VV and intercostal spaces or in the II intercostal space in the midclavicular
lines (with pneumothorax). Drainage (rubber or plastic tube) is introduced into the pleural
cavity using a trocar. The use of a trocar provides a longer
tightness of the pleural cavity. The diameter of the drain must not exceed the inner diameter
trocar. Local anesthesia of the skin in the intercostal space is performed by infiltration to
parietal pleura. Conduct a horizontal skin incision with a length of approximately 1.5 cm, try
on
the length of the portion of the tube to be inserted into the pleural cavity. Trocars create a
channel
over the upper edge of the rib and, after getting into the pleural cavity, the stylet is removed
and introduced
a drainage tube, the distal end of which is transmitted by the clamp and connect the active
suction or Bulau valve. The drainage fix is cozy to the skin with a U-shaped seam, the ends of
the thread
tied with a bow.)
Task № 5
Patient 18 years old, complaints of constant wet cough with sputum discharge and an admixture of
pus. Sometimes streaks of blood appear after exercise. Subfebrility up to 37.5 °С, general weakness.
Considers herself ill for about one year, explains his condition with pneumonia a year ago. In
childhood, he often had colds and pneumonia. Objectively: body temperature 37.3 °C, respiratory
rate 20 in 1 min, pulse 86 in 1 min, blood pressure 100/70 mm RT. Art.
bronchiectatic disease
Page 5
2020/5/21
● Clinical blood test.
● Biochemical blood test.
● CAS
● In the clinical analysis of sputum, red blood cells, white blood cells, detritus, Dietrich’s
tubes are found (
"Casts" of the bronchi containing cholesterol, sweet, elastic fibers), elastic and
collagen fibers.
● Sputum bacterioscopy can detect a significant number of microbial bodies.
● X-ray of the lungs
● Spirography
● Bronchography
● Bronchoscopy is important to assess the severity of suppuration (endobronchitis), for
dynamic monitoring of the process, for endobronchial sanitation.
● CT
3) possible treatment methods
Surgical (resection of the affected lobe of the lung or segment of the lung)
thoracotomy (open or video-assisted thoracoscopic), resection of altered
areas of the lung within the segment (s), fate (lobes), very rarely
remove all pulmonary pulmonectomy. With bilateral localization of bronchiectasis surgery
perform in two stages with an interval of 6-12 months.
Conservative treatment:
• antibiotic therapy during an exacerbation of the disease
The drugs of choice are amoxicillin / clavulanic acid (clavulanate), CS II
generations (cefuroxime), second-generation hormones (ciprofloxacin), or respiratory
hormones (gatimak,
gatibact).
• detoxification therapy (heavy drinking up to 2-3 liters per day is recommended (with
absence of contraindications): linden, raspberry tea, infusions of shipsyna, juices, fruit
drinks).
Neohemodesis, isotonic sodium chloride solution, 5% solution are administered intravenously
glucose
• immunomodulatory therapy, normalization of general and pulmonary reactivity
levamisole, thymalin, diuciphone, T-activin, eleutherococcus extract, propolis, pantocrine,
Albumin Transfusion, Intralipid
4) directions of conservative treatment.
• sanitation of the bronchial tree, removal of purulent bronchial contents and sputum -
The most important therapeutic measure. It is carried out using instillations through the nasal
catheter (method of intratracheal washing) or with bronchoscopy, introducing therapeutic
antiseptic solutions (10 ml of 1: 1000 solution of furatsilina, 10 ml of 1% solution of
dioxidine and
etc.), Mucolytics (mucosolvin, acetylcysteine - 2 ml of a 10% solution). For relax
sputum discharge, it is recommended to take bronchodilators (especially before positional
drainage, chest massage).
• sanitation of upper LH (consists in the thorough treatment of teeth, chronic tonsillitis,
pharyngitis, diseases of the sinuses, reduces relapses of exacerbations of BEH, increases
total patient reactivity).
• exercise therapy, massage, breathing exercises, physiotherapy
Indications for surgical treatment are:
● Limited BY (within individual segments or lobes) without pronounced
bronchial obstruction. Resection of the lung eliminates the focus of chronic infection.
Significant improvement or complete recovery after lung resection
observed in 97% of patients;
● not the effectiveness of conservative treatment.
Contraindications to surgery are:
• COPD, and chronic pulmonary heart disease,
• Amyloidosis of the kidneys with renal failure
Task № 6
The patient is 26 years old, complains of a constant wet cough with purulent sputum, especially in
the morning. Occasionally there are streaks of blood after physical activity. General weakness. She
has been suffering from colds and pneumonia since childhood. Objective: body temperature 37.3 °C,
respiratory rate 20 per 1 min, pulse 86 per 1 min, blood pressure 100/70 mm Hg. Art. At radiography
of lungs revealed: deformation and strengthening of a pulmonary drawing due to peribronchial
fibrous and inflammatory changes pulmonary pattern in the form of honeycombs in the lower lung
segments, thin-walled cyst-like clarifications with fluid level in the middle lobe of the right lung
Bronchiectatic disease.
● Clinical blood test.
● In the clinical analysis of sputum, red blood cells, white blood cells, detritus, Dietrich’s
tubes are found (
"Casts" of the bronchi containing cholesterol, sweet, elastic fibers), elastic and
collagen fibers.
● Sputum bacterioscopy can detect a significant number of microbial bodies.
● Spirography
● Bronchography
● Bronchoscopy is important to assess the severity of suppuration (endobronchitis), for
dynamic monitoring of the process, for endobronchial sanitation.
● CT
3) or is endoscopic examination indicated?
So, bronchoscopy (FBS) is shown
- limited BY (within individual segments or lobes of the lungs) without pronounced
bronchial obstruction. Resection of the lung eliminates the focus of chronic infection.
Significant improvement or complete recovery after lung resection
observed in 97% of patients.
- inefficiency of conservative treatment.
• COPD, and chronic pulmonary heart;
• Amyloidosis of the kidneys with renal failure.
pulmonary:
-bleeding;
Empyema of pleura;
Pulmonary emphysema;
-Piopneumothorax;
extrapulmonary:
Chronic pulmonary heart
Amyloidosis of the kidneys.
Prevention consists in timely diagnosis and treatment
Task № 7
A 45-year-old patient complains of a cough with a small amount of purulent sputum with streaks of
blood. There was a double selection of about 100 ml. The patient has pneumonia about 3 weeks ago.
Status of patient is medium-heavy. Pulse 96 for 1 min, blood pressure 110/70 mm Hg. Art. Frequency
of respiratory movements 22 per 1 min. At auscultation over the left lung breath is rigid. Above the
right lung hard breathing is weakened, above the lower lobe audible wet rales of various calibers.
Percussion - intense shortening of the sound above the lower lobe
lung abscess
2) further examination methods need to be appointed?
● OAK: leukocytosis, stab shift, toxic neutrophil granularity, increase
ESR
● WAS: moderate albuminuria, cylindruria, microhematuria.
● LHC: an increase in nonspecific acute phase indicators: sialic acids,
seromucoid, fibrin, α of the second γ - globulin.
● sputum analysis: purulent with an unpleasant odor, when standing is divided into three
layers. At
microscopy - large numbers of leukocytes, elastic fibers, crystals
hematoidin, fatty acids.
● X-ray examination (in 2 projections)
● CT
3) features of conservative treatment.
Antibiotics of choice for lung abscess are: amoxicillin / clavulanic
acid of 2.4 g with an interval of 6:00 with the subsequent transition to oral administration of
625 mg s
an interval of 6-8 hours or ampicillin / sulbactam - intravenously; possible application
cefaperazone / sulbactam intravenously or with a combination of amoxicillin 0.5-1.0 g s
an interval of 8:00 and metronidazole 0.5-1.0 g with an interval of 8-12 hours intravenously
with
subsequent oral administration (step therapy). Toward alternative treatment regimens
include: a combination of lincosamides - clindamycin 600 mg with an interval of 6-8 hours
with
subsequent transition to oral administration - 300 mg with an interval of 6:00 with an
aminoglycoside or
CS of III-IV generations (cefotaxime 2 g with an interval of 8:00, ceftriaxone 2 g with an
interval
12-24 hours;
a combination of FC II-III generations (ciprofloxacin, levofloxacin) with metronidazole;
monotherapy of IV generation PF - moxifloxacin (400 mg 1 time per day, followed by
switching to oral administration - 400 mg once a day) or carbapenems - meropenem or
imipenem (1-2 g with an interval of 8:00). The duration of ABT is determined individually,
but, as a rule, it is more than 3-4 weeks.
Infusion therapy:
- Glucose solution 5% 200-400 ml VVK 1-2 r / d;
- sodium chloride solution 0, 9% 200-400 ml VVK 1-2 r / d;
- Ringer's lactate solution of 200-400 ml of VVK 1-2 r / d.
Draining interventions - Monaldi closed thoracoabcesticostomy
Indications: a destruction cavity of more than 5 cm in diameter with a peripheral location.
contraindications:
● pulmonary hemorrhage,
● location of the abscess in the projection of the main vessel, heart,
● impaired blood coagulation.
Radical interventions:
indications:
● massive as well as repeated pulmonary hemorrhages
● chronic abscesses;
● progression of purulent process on the background of intensive care with the involvement
of
receptions of "minor" surgery;
● the inability to exclude a malignant tumor.
Contraindications to radical interventions:
● respiratory failure III tbsp.,
● bilateral lung damage,
● stand cardiac decompensation,
● paresis, paralysis,
● concomitant inoperable malignant tumors,
blood diseases with increased bleeding.
5) possible complications of the course and their prevention?
- Pyopneumothorax;
- mediastinal and subcutaneous emphysema;
- empyema of pleura;
- pulmonary bleeding;
- sepsis
- metastatic brain abscess.
Prevention is the timely diagnosis and treatment of the underlying disease
Task № 8
A 54-year-old patient became acutely ill when he experienced pain in the right half of his chest. The
temperature is – 39.8 ºC. The cough is wet. Breathing is frequent. On the 10th day, when coughing,
he noted the release of a large amount of foul-smelling sputum. The patient's condition improved.
The temperature dropped. However, the cough remains with a lot of sputum.
lung abscess
- OAK: leukocytosis, stab shift, toxic granularity of neutrophils, increase
ESR
- WAS: moderate albuminuria, cylindruria, microhematuria.
- LHC: an increase in non-specific acute phase indicators: sialic acids,
- sputum analysis: purulent with an unpleasant odor, when standing is divided into three
layers. At
- X-ray examination (in 2 projections)
- CT
3) or is the continuation of conservative treatment indicated?
So shown
Before receiving the results of a bacteriological study, broad antibiotics are prescribed
spectrum acting bactericidal on the main groups of possible pathogens. Among
penicillin group drugs have such properties amino (ampicillin iv, v / m
every 4-6 hours, 4-6 g / d, amoxicillin i / m, i / v 1 g 2 r / d, with normal renal function - 2-
12 g / s) and acylureidopenicillins (iv azocin in 8 (4 times 2 g) -15 (3 times 5 g) g / d,
IV meslocillin every 4-6 hours 12-16 g / d, piperacillin every 4-6 hours 12-16 g / s). Daily
the dose of penicillin is 6-12 g. It is advisable to use dosage forms in the composition
which include beta-lactamase inhibitors (clavulanic acid, sulbactam, tazobactam).
Good results are obtained using the second cephalosporins (cefuroxime sodium 1.5 g 4 p /
d or 3 g 3 r / d, cefamandole 0 5-1 g 4 r / d), third (cefotaxime 1-2 g 3-4 r / d, ceftriaxone 2-4
g 1 r / d, sometimes 1-2 g 2 r / d, cefadizime 1-2 g 2 r / d, cefoperazone 1-2 g 2-3 r / d,
ceftazidime
(Fortum) 1-2 g 2-3 r / d, goes well in 1 injection with metragil: 0 5 g ceftazidime + 100 ml
0. 5% solution of metragil) and the fourth (moxalactam 2-12 g / d in 3 divided doses,
cefpirome iv in a jet
or drip 1-2 g / s) of generations in doses of 2-6 g / day. It is advisable to combine these drugs
with metronidazole, ornidazole (1-2 g / day).
Monotherapy is carried out with carbapenems (imipenem, meropenem), a daily dose of 2-4 g /
day.
II generation fluoroquinolones (ciprofloxacin, ofloxacin, lomefloxacin 200-400 mg / day), III
generation (levofloxacin, sparfloxacin 1000 mg / day), IV generation (moxifloxacin,
gatifloxacin 1000 mg / day) is usually combined with metronidazole (ornidazole) or
clindamycin (up to 1, 8 g).
Infusion therapy:
4) contraindications to surgical treatment.
contraindications:
- pulmonary bleeding,
- the location of the abscess in the projection of the main vessel, heart,
- violation of hemocoagulation.
- respiratory failure of the III century,
- bilateral lung damage,
- stand heart decompensation,
- paresis, paralysis,
- concomitant inoperable malignant tumors,
- blood diseases with increased bleeding.
5) possible complications with conservative treatment?
- Empyema of pleura
- Pyopneumothorax
- Pulmonary bleeding
Task № 9
A patient suffering from a chronic abscess of the left lung, on the background of a satisfactory
condition appeared severe pain in the left half of the chest, shortness of breath, fever. Breathing on
the left is weakened; above the upper lobe is heard amphora breathing.
1. What is the diagnosis?

Abscess of the upper lobe of the left lung with moderate severity in the acute phase.
2. What examination methods should be prescribed additionally?
● Panoramic radiography of the chest cavity in two projections (direct and
lateral).
● CT scan of the chest.
● Bronchoscopy
● Sputum examination.
3. Is bronchoscopy indicated?
Yes.
4. Possible complications of therapeutic treatment? Antibiotic resistance
residual dry abscess cavity and epithelialization of the cavity from the mouth of the draining
bronchi.
5. Indications for surgical treatment.
The presence of a chronic abscess
Task № 10
The patient is 19 years old, for 13 days is being treated in the therapeutic department for lower left
pneumonia. From the 10th day, the temperature rose to 39 ºC, the pain in the left half of the chest
intensified, and shortness of breath appeared. The number of leukocytes increased from 8 to 11x109
/liter.

Acute left-sided writing is pneumonic of pleural empyema (or pleuropneumonia).
● Survey radiography in two projections.
● pleurography.
● Puncture of the pleural cavity.
● Thoracoscopy.
● Examination of punctate from the pleural cavity and sputum.
3. Directions of conservative treatment.
Diagnostic pleural puncture in the 7th intercostal space in the rear axillary
lines.
With limited empyema, puncture at the point due to chest x-ray
cells in a direct, lateral, right or left oblique projections.
Thoracocentesis with drainage of the pleural cavity.
Active aspiration.
Lavage of empyema cavity with Decasan antiseptic solutions using lavage
tracheobronchial tree - in a volume of 100 ml. (Up to 3 times a day).
Possible introduction of Dekasan:
● through microtracheostomy - 25-50 ml 1-2 times a day;
● through a transnasal catheter - 5-10 ml once a day;
● by ultrasonic inhalation method - 5-10 ml 1-2 times a day;
If conservative treatment will be ineffective.
5. Possible complications of the course, their prevention?
● Bleeding - intrapleural or pulmonary due to arrosion of the vessel wall.
● Formation of bronchial or thoracic fistula.
● Transition to the chronic stage - the formation of a residual cavity as a result
development of rigidity processes, pneumosclerosis.
● Aspiration of the contents into the respiratory tract, asphyxia, sepsis.
● Amyloidosis of the kidneys.
● Timely and adequate treatment
Task № 11
The patient, 28 years old, is being treated in the therapeutic department with a diagnosis of acute
abscess of the upper lobe of the right lung. Against the background of a stable severe condition,
there were sudden severe pains in the right half of the chest, chills, shortness of breath, pallor with a
bluish tingle to the skin. Pulse 130 in 1 minute. At auscultation in lungs the right of breath is not
listened. The chest radiograph in the right pleural cavity shows a horizontal fluid level of up to 3 ribs,
the lung is collapsed by 1/2 the volume, and the mediastinum is shifted to the left.
Acute abscess of the upper lobe of the right lung, severe course, complicated
pyopneumothorax.
Pleurography.
CT scan of the chest.
Puncture of the pleural cavity.
Thoracoscopy
Examination of punctate from the pleural cavity, antibioticogram.
Blood chemistry.
3. Possible complications.
The formation of bronchial or thoracic fistula.
Transition to the chronic stage.
Aspiration of the contents into the respiratory tract, asphyxia, sepsis.
Severe condition of the patient.
Pyopneumothorax.
5. Prevention of complications.
Timely diagnosis of abscess.
Timely and adequate treatment of the abscess.
Adequate drainage of the abscess
Task № 12
Male 27 years, complains of shortness breath, dry cough, pain in the right side of the chest. From the
anamnesis: the pain appeared suddenly during exercise, smokes up to 20 cigarettes a day for 10
years. What disease should be suspected? What additional examination methods will confirm the
diagnosis?
1. Establish a clinical diagnosis.
Acute right-sided spontaneous pneumothorax.
2. Additional examination methods.
● Chest x-ray.
● Puncture of the pleural cavity.
● Thoracoscopy.
● electrocardiography.
3. Differential diagnosis.
● Coronary heart disease.
● Pleuropneumonia.
● Pleurisy.
4. Treatment.
A) Etiological causes are detected during thoracoscopy:
thoracoscopy is performed under local anesthesia along the anterior axillary or
midaxillary line.
B) With pneumothorax of large volume or inefficiency of the puncture method of treatment
surgical intervention in the volume of urgent thoracocentesis with drainage is shown
pleural cavity:
● active aspiration of air from the pleural cavity by electric aspirators or
triampul system;
● passive aspiration of air from the pleural cavity with Bullau (if not possible
create negative pressure in the pleural cavity with active aspiration).
C) If the lungs are not molten for 3 days from the onset of pneumothorax,
it is necessary to clarify the cause of pneumothorax and change the treatment tactics:
● video thoracoscopy, during which, according to indications, was destroyed,
pleurisy, chemical pleurodesis are scarified;
● thoracotomy is indicated for large bulas (more than 2 cm), during which
An atypical lung resection was stitched or performed.
5. Possible complications.
● Acute respiratory failure.
● Pulmonary edema.
● hemopneumothorax.
● Pleurisy.
● Empyema of pleura.
Task № 13
The patient was taken from the scene of the accident. Objectively in the patient: cyanotic skin, BP
28–30 per minute, lag of the left half of the chest when breathing. On palpation: the left, crepitation
of fragments V–VII ribs and local subcutaneous emphysema. Percussion: shift of dullness of heart to
the right, box shade to the left. What was the patient's diagnosis and what were the tactics of
treatment of this patient?
1) establish a clinical diagnosis.

Fracture of the V-VII ribs on the left, traumatic pneumothorax.
2) Emergency care at the prehospital stage:
- anesthetize.
- apply an occlusive dressing with an external C. pneumothorax.
- conduct pleural puncture in the second intercostal space along the midclavicular line with
inner class pneumothorax.
3) Differential diagnosis.
Hemothorax, whether there was a rupture of cysts.
4) Additional examination methods.
X-ray of OGK, CT, ultrasound.
5) Surgical treatment.
Drainage, videothoracoscopy, pleurodesis.
Task № 14
Patient 33 years 6 hours after childbirth has hoarseness of voice, a feeling of distension behind the
sternum. Objectively: tension and subcutaneous emphysema in the area of the jugular notch of the
sternum. On the review radiograph of the chest revealed an increase in the transparency of the
anteriorsuperior interstitium. What syndrome can be suspected? What are the tactics of treatment
of this patient?
1) establish a clinical syndrome.

Hamman's ( Hemman's) syndrome (spontaneous pneumomediastinum) Trida: pain or bursting
beyond
sternum, shortness of breath, swelling (puffiness) of soft tissues.
CT, FGDS, FTBS (tracheobronchoscopy), x-ray in the direct and lateral projections, x-ray of
the esophagus.
3) Possible complications.
Iatrogenic rupture of the trachea or esophagus, circulatory failure, cardiac tamponade.
4) Tactics of treatment.
Bed rest, oxygen therapy, analgin analgesia 2 ml / m 2r / d, antibiotic therapy
for prophylaxis 3-5 days, emsef 1 bottle 1 time per day.
5) Indications for surgical treatment.
Inefficiency of conservative therapy, intense pneumomediastinum
Task № 15
A 56-year-old man complains on swelling of the neck, pain behind the chest and neck when
swallowing, fever up to 39 ºC, shortness of breath. From the anamnesis: 3 days ago he was treated
by a dentist for caries complicated by periostitis of the mandible. According to on the review
radiograph of the chest infiltration with air bubbles was detected in the deep cellular spaces of the
neck and paraesophageally to the level of Th2. What is the patient's diagnosis and what are the
treatment tactics?
1) Establish a clinical diagnosis.

Odontogenic mediastinitis.
2) Ways of spreading the purulent process in this disease. Spread
occurs along the deep fascial and cellular spaces of the neck through prececeral
space and vascular fissures associated with the anterior mediastinum
Radiography in the anteroposterior, lateral and oblique projections.
4) Possible complications.
Sepsis, multiple organ failure syndrome.
5) Tactics of treatment of the patient.
Elimination of the root cause. With the ineffectiveness of conservative treatment:
mediastinotomy according to
Razumovsky, surgical treatment completes the drainage of antibiotic + antiseptic
(ciprofloxacin 500 mg 2 r / d + rn furatsilina 1: 5000)
Task № 16
The patient is 53 years old, complained of belching mucus and food debris, even 3–4 hours after
eating, chest pain when swallowing is not associated with exercise, bouts of "night cough", weight
loss. Ill for about 2 years, the condition gradually deteriorated. What disease can be suspected? What
diseases is it necessary to conduct a differential diagnosis with. What additional examination
methods will confirm the diagnosis?
1) Establish a clinical diagnosis.

GERD.
2) differential diagnosis, pharmacological tests.
Differential diagnosis: angina pectoris, asthma, peptic ulcer and 12 duodenal ulcer.
Pharmacological tests: • with alginates / antacids (single dose
the product contains alginate or antacid in a standard dose; if heartburn disappears or
significantly
decreases - the test is positive, the etiology of heartburn - reflux; if heartburn persists - test
negative, etiology of heartburn is different. • IPP - test (trial administration of IPP in a
standard dose
within 7 days).
3) additional examination methods.
Esophagoscopy (+ biopsy), intra-esophageal daily pH monitoring, fiber optic
spectrophotometric intraesophageal monitoring of bilirubin, intraesophageal method
impedanometry, fluoroscopy, esophagomanometry, IPP test, acid perfusion test
Bernstein, video capsule endoscopy.
4) classification (clinical stages) of the disease.
1. Typical reflux syndrome.
2. Syndrome of retrosternal reflux pain.
3. extraesophageal manifestations of GERD:
With established cause: - chronic cough, reflux laryngitis; bronchial asthma;
damage to tooth enamel.
With the provided connection: - pharyngitis; sinusitis, recurrent otitis media, idiopathic
pulmonary fibrosis.
4. Refractory GERD.
5) treatment tactics, indications for surgical treatment.
Lifestyle modernization and diet therapy. Pharmacological therapy: rabeprazole-20 mg 1 time
/
days 4-8 weeks, maalox 1 sachet one hour after each meal, "Venter" 1g 3r / d. Indications
surgical treatment: - the presence of a hiatal hernia; - the length of the NSS
(lower esophageal sphincter) less than 3 cm with a predominantly thoracic location; - hypo
akinetic type of esophageal motility disorder - the presence of post-insomnia symptoms
diseases
Task № 17
The patient is 47 years old with complaints on difficulty swallowing water and food, belching food,
bad breath, and weight loss. When trying to perform EFGDS, the endoscope does not pass below the
cervical esophagus. What is the most probable diagnosis and what are the tactics of a general
practitioner after consulting this patient?
1. Establish a clinical diagnosis.

Diagnosis: Achalasia cardia? (Esophageal carcinoma)
2. Differential diagnosis:
- esophagospasm
peptic esophagitis
esophageal stenosis
esophageal stricture
- Tumors of the mediastinum
-cardiosophageal cancer
esophagus diverticulum
3.Add survey methods:
-contrast radiography of the gastrointestinal tract in the central and lateral projections
mucosal biopsy
Pharmacological tests (nitroglycerin and amyl nitrite) under x-ray control.
CT, MRI
4. Have complications:
esophagus
esophageal-tracheal fistula
Cachexia
Secondary infection
5. Methods of surgical treatment:
Heller operation
-esophagocardiomyotomy with phrenoplasty according to Petrovsky
Task № 18
The patient is 34 years old, complains of shortness of breath during physical activity, chest pain,
palpitations. From the anamnesis: about a month ago during a fight he received a kick in the
abdomen. On the radiograph – high standing left dome of diaphragm (to the level of 4 ribs), the
displacement of the interstitium to the right. What is the most probable diagnosis and treatment
tactics?
1. Establish a clinical diagnosis

Diagnosis: Post-traumatic diaphragm relaxation on the left
2. Differential diagnosis (with a gap).
Diaphragm with diaphragm rupture
It is necessary to differentiate the relaxation of the diaphragm with a large diaphragmatic
hernia
(diaphragm rupture)
- during relaxation, the contour of the diaphragm is traced in the form of a regular arcuate
line,
passing from the anterior chest wall to the posterior and from the lateral chest wall to the
mediastinum, which
usually does not happen with a hernia;
- during relaxation, all abdominal organs are located under the diaphragm, therefore, detection
the contour of the latter below the upper border of the dome is evidence of a hernia;
-when changing the position of the patient from a vertical position to a horizontal form and
the continuity of the contour of the diaphragm during relaxation is preserved;
- with a hernia, the protrusion often changes its shape, since various organs are displaced
unequally; • involvement in the walls of the stomach and intestines at the diaphragm level
occur only
with keel;
- with keel, the angle between the arch of the stomach and the wall of the intestine remains
open, with relaxation -
closed from above by a diaphragm contour;
an x-ray picture of a diaphragmatic hernia containing intestinal loops is characterized
variability;
3.Add survey methods:
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2020/5/21
- X-ray data Given when using fluoroscopy and radiography in conditions
gastrointestinal contrast
- pneumoperitoneum
- CT
4. Possible complications
Unexplained complications are acute and chronic gastric upset with its possible
gangrene, ulceration of the gastric mucosa and bleeding, rupture of the diaphragm.
5. Methods of surgical treatment.
Surgical treatment. Duplication of the left dome of the diaphragm through the chest access
Two main types of interventions are used.
(Operations on the diaphragm aimed at its reduction and strengthening):
● plastic with our own tissues or autoplasty (corrugation, duplication,
frenoplication)
● plastic diaphragm reinforcement using alloplastic synthetic materials
(alloplasty
Task № 19
The patient, 46 years old, complained of chest pain and heart failure after eating, heartburn,
belching. Laboratory inspection shows anemia of average degree. During EFGDS reflux esophagitis,
deformation of the cardiac part of the stomach was detected. What disease can be suspected? What
diseases should be diagnosed with? What additional examination methods will confirm the
diagnosis?
1. Establish a clinical diagnosis

Diagnosis: Hernia of the esophageal opening of the diaphragm (cardiac, sliding)
2. Differential diagnosis (with cardioesophageal cancer).
cardioesophageal cancer
Anemia, weight loss,
- The gas bubble of the stomach is deformed
Folds of the mucous membrane of the abdominal segment: nose relief malignant
(flattening of folds, compaction or loss of relief)
- Stravochid is not expanded, mucosal metaplasia
Biopsy-atypical cells
3.Add survey methods
X-ray examinations (polypositional multi-axis then with contrasting
especially in the Trendelenburg position with compression of the anterior abdominal wall.
4. Have complications
- pinched hernial contents with subsequent necrosis
-slunkova or esophageal bleeding,
esophagitis (including erosive, ulcerative),
-virazkootvoreniya in the hernial part of the stomach,
Scar stenosis
- aspiration diseases (chronic bronchitis, secondary bronchiectasis, pneumonia, abscesses
lung, pneumofibrosis)
-invasion of the esophagus into the stomach,
- malignancy.
5.Live methods of surgical treatment
Cruroraphy stitching behind the esophagus of the medial legs of the diaphragm
Esophagofundoplication - creating around the esophagus valve
Pyloroplasty (as a result of compression of the vagus nerves pylorospasm may develop)
Task № 20
A 49-year-old patient who abused alcohol developed vomiting with blood impurities, severe pain in
the left side and left hypochondrium, gradually increased shortness of breath, cough and fever up to
39 ºC. On the review radiograph of the chest for darkening of the left pulmonary field due to
infiltration and fluid level to the VI rib. During the drainage of the left pleural cavity up to 1.8 L.
brown exudate with impurities of pus and fibrin was obtained. Over the next 24 hours, up to 1.4 L.
brown exudate with manure and food impurities was obtained by drainage. What disease should be
suspected? What additional examination methods will confirm the diagnosis?
1) what diagnosis can be suspected.

Gullet gap. Left-sided pyopneumothorax.
2) additional examination methods.
EGD, contrast radiography, blood amylase, ultrasound of the abdominal organs.
3) differential diagnosis.
Mallory-Weiss syndrome, acute pancreatitis, cirrhosis of the liver (bleeding from varicose
veins
dilated veins of the esophagus), perforated gastric ulcer.
4) possible complications.
Mediastinitis, pleurisy, empyema of the pleura, sepsis.
5) possible methods of surgical treatment.
In the early stages after rupture, the operation of suturing the damaged wall of the esophagus
is indicated, and in
later (later than 24 hours) - drainage of the mediastinum and pleural cavity on the side
rupture without interference on the esophagus
Task № 21
Patient M., 42 years old, a resident of the village. Heavy snow fell at night. He was forced to reject, in
a hurry. There was a temporary pain in the right part of the upper chest. He returned to the house.
Shaved. There was a slight shortness of breath, and after a few minutes – dizziness. Shortness of
breath increased. An ambulance was called
1) What diagnosis could the doctor suspect?

Spontaneous pneumothorax.
2) What are his actions immediately?
Calm, oxygen therapy, percussion and auscultation of the lungs.
3) What is the further tactic?
Emergency hospitalization in the thoracic department.
4) What is an additional examination of the patient upon admission?
X-ray analysis of OGK.
5) Do I need a clinical blood test?
So, pulse oximetry (detection of hypoxemia, hypercapnia), determination of blood pH
(respiratory
acidosis)
Task № 22
The patient threw away the snow in the morning, hurried, had to strain a lot, because the snow was
heavy, wet. There was pain in the right hypochondrium, which was aggravated by breathing, which
prevented deep breathing.
1) What is the doctor’s tactics?

Calm, oxygen therapy, percussion and auscultation of the lungs,
hospitalization in a surgical hospital.
2) What additional examination is needed?
Radiography of OGK and OBP.
3) In what urgent department do you need to deliver the patient?
Thoracic department.
4) What is the final diagnosis?
Task № 23
Patient Z., 52 years old. In the evening he returned home in a crowded vehicle. There was pain in the
left half of the chest at night. In the position on the left side, the pain calmed down a bit. When he
got up in the morning, he felt shortness of breath and increased pain, which prevented him from
putting on his shoes. The doctor was called.
1) His actions?
Calm, carry out percussion and auscultation of the lungs, oxygen therapy.
2) What disease is suspected?
3) In which department to deliver the patient?
Thoracic department
Task № 24
Patient I., 28 years old. He worked physically, transferred goods from warehouses to cars for 3 days
in a row. In the evening there was fever, chills, coughing, shortness of breath. He returned to the
doctor, drank aspirin, and was somewhat relieved. In the morning he went to work, but shortness of
breath did not allow him to do so. An ambulance was called. After examination, the patient was
hospitalized in the intensive care unit.
1) What diagnosis was suspected?

spontaneous pneumothorax
2) How can I confirm it?
Percussion, auscultatory, radiography of OGK
3) What examination should be performed in a hospital?
X-ray analysis of OGK (CT if possible), pulse oximetry, blood pH.
4) What are the indications for hospitalization in the intensive care unit?
Low saturation, (acidosis?)
5) What manipulations needed to be performed immediately?
Drainage into the pleural cavity in the II mizhreb. along the midclavicular line
Task № 25
Patient Sh., 28 years old. There was pain in the right half of the abdomen in the morning. There was
no chair. Urination without features. Examined by an ambulance doctor: the tongue is slightly dry.
The abdomen is painful in the right half, there is a slight muscle tension. Schotkin-Blumberg
syndrome is not clearly expressed.
1) What diseases do you need to differentiate the disease with?

Acute appendicitis, mesadenitis, acute cholecystitis, intestinal perforation, intestinal
obstruction, diverticulitis of the large intestine, Ileocecal intussusception.
(right-sided adnexitis, ectopic pregnancy (which was interrupted), cyst of the right ovary
- if it is a woman)
2) What survey methods are appropriate?
Palpation, percussion, auscultatory - exclude / confirm surgical
symptoms
KLA, BH an. blood, ultrasound of the abdominal cavity, CT.
3) What specialist need a consultation (surgeon, infectious disease specialist, general
practitioner)?
Surgeon
4) What are the methods of radiation research?
X-ray analysis of emergency and OGK, CT;
5) What are the methods of laboratory research?
KLA, BH an. blood, detect.
Task № 26
Patient V., 48 years old, became acutely ill after a little physical work, when in the evening there was
aching pain in the right lower half of the chest, the temperature rose to 39 °C, sweating. More than a
year ago there was a blunt chest injury, the pain lasted for several weeks. Took painkillers. On
examination: pale, moist skin. At percussion – insignificant dulling on the right in the lower
departments, auscultatory – breathing in the same departments is weakened.
1) Diagnosis?
lung abscess
2) What research methods should be applied?
● UAC: leukocytosis, stab shift, toxic granularity of neutrophils,
increase in ESR.
● WAS: moderate albuminuria, cylindruria, microhematuria.
● LHC: an increase in nonspecific acute phase indicators: sialic acids,
● Sputum analysis: purulent with an unpleasant odor, when standing, it is divided into three
layers. At
● X-ray examination (in 2 projections)
● CT
3) What diseases should be used for differential diagnosis?
● bronchogenic cancer;
● bronchiectasis;
● empyema of the pleura with bronchopleural fistulas;
● tuberculosis;
● pulmonary bulla or air cyst that disintegrates;
● pulmonary rejection;
● subphrenic or hepatic (amoebic, echinococcal) abscess with perforation
in the bronchus;
● Wegener granulomatosis.
4) What research methods should be preferred?
X-ray examination and CT examination.
5) What are the possible complications?
● Pyopneumothorax;
● Mediastinal and subcutaneous emphysema;
● Empyema of pleura;
● Pulmonary hemorrhage
● Sepsis;
● Metastatic brain abscess
Task № 27
The patient is 53 years old, handyman. He suffered from pleurisy two years ago. He had a pleural
puncture several times and refused inpatient treatment. Two days ago, fever, weakness, severe
cough, went to a glass of green sputum.
1) What are the examination methods at home?

Objective signs of the disease (symptoms of acute purulent come to the fore
process): a) review: forced (semi-sitting) position of the patient in bed; - general
weakness, - acrocyanosis; - shortness of breath (more than 24 respiratory movements per
minute): - increase
body temperature up to 39-40 ° C; loss of appetite for sleep disturbances: peripheral edema on
limbs; enlarged liver; 6) palpation: - pastoscopic chest, smoothness
intercostal spaces with a large empyma (on Bots urazeneya) lag in breathing
chest on the side of the lesion; soreness on the side of the lesion; weak voice
trembling c) percussion: the results of percussion depend on the prevalence of the process -
blunting of percussion sound over clusters of pus tympanitis over areas of gas accumulation
(in case of pyrothalmothorax) d) auscultation: - breathing is sharply weakened or not heard (in
depending on the prevalence of empyema).
2) Which specialist should the patient be referred to?
thoracic surgeon
3) What are the examinations in the clinic?
X-ray examination, puncture of the pleural cavity.
clinical blood test - leukocytosis, shift of the formula to the left, increase in ESR,
lymphocytopenia, anemia, clinical analysis of urine - in the initial stages of the disease
there are no changes, and they depend on the stage of the disease, a biochemical blood test -
hypoproteinemia, an increase in 9-globulins, electrolyte shifts, water-electrolyte
violations; B studies of punctate from the pleural cavity and sputum - the presence of
pathogenic
microflora.
4) What is the diagnosis?
Empyema of the pleura.
5) What is the treatment?
Surgical intervention :
Surgery performed on an outpatient basis - pleural puncture.
inpatient surgery:
● pleurectomy with lung decortication;
● rehabilitation of the pleural cavity;
● previous intubation of the opposite main bronchus with total or subtotal
unilateral defeat;
● thoracoscopy;
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2020/5/21
● thoracotomy.
Drug treatment:
Antibacterial therapy: cefazolin (i / v drip preparation (1 g) is diluted in 250 ml
isotonic sodium chloride solution.)
For allergies to b-lactams, vancomycin (daily oral dose for adults
is from 500 mg to 1 g, for children - 40 mg / kg body weight, divided into 3-4 doses, the
course
treatment 7-10 days).
Analgesic therapy:
Non-narcotic and narcotic analgesics:
Tramadol (100 mg -2 ml 3 times / m for 2-3 days),
Ketorolac (25 mg 4 times / day (every 6 hours) IM, IV, 6 days)
Paracetamol (by mouth, 500 mg 4 times a day, 5 days)
Antiseptic for the treatment of the surgical field:
Chlorhexidine 0.05% aqueous solution externally once
Task № 28
Patient C, 43 years old. Gradually there was pain in the right half of the chest in the area of the
costal arch. Took analgesics. The pain disappeared for several hours. Objectively: on the right in the
area of the costal arch slight swelling, smoothed intercostal spaces, pain on palpation, local pain on
percussion. Clinical analysis of blood: er. – 3,6х109 /l, Hb – 108 g/l, L – 6,8х1012/l.
1) What diseases is differential diagnosis with: osteomyelitis, traumatic

myositis, subphrenic abscess, subhepatic abscess, cholecystitis, pleurisy, others
pleural disease?
Diagnosis: chronic calculous cholecystitis.
Differential diagnostics:
- osteomyelitis: intoxication syndrome, prolonged pain, local inflammatory changes,
frequent fistulas, Rtg (sequestra, usury), wedge.an blood: leukocytosis, shift of the formula to
the left,
high ESR;
- Traumatic myositis: a history of trauma, local inflammatory changes, hematomas,
intense shoots bringing nature pain
- Subphrenic abscess: hectic fever,
intoxication syndrome; pain-constant, intense with
radiating to the scapula; shortness of breath mixed, tachypnea, hiccups;
leukocytosis, left shift and ↑ ESR;
- subhepatic abscess: intoxication syndrome, intense intense
pain, jaundice, dyspeptic disorders, leukocytosis, shift
formulas to the left and ↑ ESR;
- Dry pleurisy: intoxication syndrome; stitching pain (aggravated by coughing,
movements) forced position - lying on the affected side; cough, shortness of breath
auscultatory - pleural friction noise, weakened breathing;
Exudative pleurisy: intoxication syndrome; dull pain; dry cough, tachypnea,
shortness of breath of a mixed nature, cyanosis; auscultatory: weakened breathing, bronchial
breath;
2) What are the additional examination methods?
- cholecystography;
- Ultrasound of the liver of the gall bladder;
- Fibrogastroduodenoscopy;
- biochemical blood test (level of total protein and its fractions, triglycerides,
cholesterol, enzymes AlAT and AsAT, electrolytes)
- Blood type and Rh factor;
3) Tactics?
Tactics: dynamic observation, hunger 1-2 days and alkaline drink.
Antispasmodics: papaverine 2% - 2 ml IM for 3 days and platifillin 0.2% - 1 ml IM in
combination with
Analgin 50% -2 ml.
4) Treatment methods?
Surgical: laparotomic cholecystectomy (laparoscopic if technically feasible),
abdominal drainage (with enlarged common bile duct, suspected presence in it
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calculi - choledochotomy, revision, removal of calculi, external drainage
duct).
Detoxification: NaCl 0.9% solution - 500 ml, Ringer-Locka 500 ml and 5% glucose solution
500 ml
Antibiotic therapy: cefazolin 1gr twice or cefuroxime 750 mg twice.
Nonsteroidal anti-inflammatory: ketoprofen 5% (100 mg-2 ml) IM three times.
Stimulation of peristalsis: metoclopramide 0.5% -2 ml three times for 3 days or
neostigmine 0.05% -1 ml IM three times.
Task № 29
Patient. M., 24 years old. Ill acutely. Complaints of pain in the upper regions of abdomen and then all
over the abdomen. On examination: the tongue is dry, the abdomen is bloated, there is no
peristalsis, on auscultation – the sound of a "falling" drop.
1) What is the diagnosis?

Acute intestinal obstruction?
2) What diseases can occur?
Differential diagnosis between spastic (paroxysmal pain, vomiting rarely, stool and gas
retention,
the abdomen is pulled in, upon palpation the protective tension is against the abdomen, Rtg is
without features) and
paralytic (constant aching pain, vomiting in the late period, stool and gas retention,
the abdomen is swollen and palpitations on palpation, Rtg-intestinal
pneumatization). Between in
Buratrational (cramping pain, vomiting without relief, no stool, stomach
symmetrically swollen and less painful on palpation, peristalsis first
increases then decreases, Rtg - Kloitber cups) and strangulation (severe pain
constant, vomiting at a height, abdomen asymmetrically swollen, painful, Rtg-Kloitber cups).
3) What is the examination in the apartment?
In the apartment: external examination, palpation and auscultation of the abdomen, digital
rectal
study.
4) What are additional examinations?
Clinical analysis of blood and urine
Biochemical blood test (electrolytes)
X-ray of the abdominal organs;
X-ray of the intestine with a barium mixture;
colonoscopy;
Ultrasound of the abdominal cavity;
5) Tactics?
Treatment begins with conservative measures aimed at restoring the passage by
intestines, which include:
- gastric emptying by placing a permanent probe with periodic
flushing;
- intravenous stimulation of peristalsis (10% sodium chloride solution 2 ml / h., 0.05%
proserin 0.1 ml / hour.)
- siphon enema;
- correction of disorders of homeostasis, hemodynamics, peripheral microcirculation.
With positive dynamics, a decrease in intoxication, stimulation of indicators are noted
hemodynamics, stool and gas outflow. No positive change or deterioration
the patient's condition against the background of conservative therapy for 8 - 12:00 dictates
indications for surgery median laparatomy, the elimination of adhesions, assessment of
intestinal viability,
sanitation of the abdominal cavity, gastrointestinal decompression.
Mandatory is the appointment of preoperative antibiotic therapy (cephalosporins II - III
generations, aminoglycosides, metronidazole).
Task № 30
Patient M., 53 years old, has complaints of difficulty in passage of food through the esophagus,
especially with rapid consumption. Frequent vomiting, occasionally heartburn
1) What diseases need differential diagnosis?

Achalasia of the cardia?
We differentiate with a narrowing of the esophagus by a tumor formation (sharp vessel,
hepato- and
splenomegaly lymphadenopathy, dysphagia, regurgitation) with gastroesophagoreflux
illness (heartburn, regurgitation with acidic stomach contents, difficulty swallowing
only when swallowing dense food, the lumen of the esophagus is not widened) with coronary
heart disease (pain or
discomfort behind the sternum,) with anorexia nervosa, with congenital membranes and
esophageal strictures
2) What additional research needs to be done?
Contrast x-ray examination of the esophagus and stomach with barium sulfate;
fibroesophagogastroduodenoscopy;
Esophageal manometry;
electrocardiography;
3) What are the complications?
Complications: esophagitis (congestive, erosive), cancer of the esophagus, diverticulum of the
esophagus, hernia
esophageal opening of the diaphragm, aspiration pneumonia.
4) Indications for surgical treatment?
- the impossibility of cardiodilation;
- lack of therapeutic effect from repeated courses of cardiodilation;
- esophageal ruptures arising from cardiodilation are early diagnosed;
- amotilous form (III-IV stage according to B.V. Petrovsky) of achalasia;
- Suspicion of esophageal cancer
Task № 31
Patient V., 44 years old, overweight about 15 kg. Worries about the pressing pain behind the
sternum, especially when leaning and lying on the right side. There are no dyspeptic complaints
1) What survey methods are offered at the first stage?

Questionnaire scale Q, ECG, ph-metry, 24-hour-impedance-ph-monitoring;
2) What radiation methods should be used before?
Ephagogastroduodenoscopy, radiography with contrast, panoramic radiography
organs of the chest and abdominal cavity, histological examination;
3) What diagnosis can be suspected?
Gastroesophageal reflux disease, pseudocardial form?
4) Treatment methods?
Conservative: alginates (Gaviscon 15 mg each) antacids (maalox, rennie, almagel 15-
20 mg) IPP (rabeprazole 20 mg / 1 time or omeprazole 40 mg / 1g), kinetics (metoclopramide
10 mg / 4 g for 4 weeks or domperidone 10-30 mg / 4 mg 30 minutes before meals);
Surgical: multipolar electrocoagulation, laser destruction, cryotherapy
mucous membrane.
Task № 32
Patient 34 years old, a resident of the village, fell ill acutely: dry cough, temperature 38.0 °C,
weakness, sweating. Objectively: skin is pale, moist, shortness of breath. At auscultation of breath
the right side is not listened.
1. Proxies, laboratory diagnostics (AS, biochem. An. Blood, Clinical analysis of urine, an.
Hydrothorax), radiography of OGK, CT gr. cells, pleural puncture, thoracoscopy
2. right-sided exudative pleurisy
3.
● hospitalization, bed rest, diet therapy (decrease in the number of carbohydrates, fluids,
exclusion of thirsty dishes)
● ABT (for example, cephalosporins 3 pok ceftriaxone 1 g 2 times a day)
● Anti-inflammatory therapy (indomethacin 0.025 g three times a day)
● Evacuation of exudate
● immunomodulatory therapy (decaris (levamisole) 100-150 mg per day for 2 3 days
followed by a 4-day break)
● Detoxification therapy (iv drip hemodesis, 5% glucose solution, ringer's ring
Task № 33
Patient 24 years old, became acutely ill. Pain in right abdomen, which increases by deep breathing.
Objective: the tongue is wet. On palpation – the abdomen is soft, no signs of peritoneal irritation
1) What additional examination methods should be applied? 2) If left breath is not

bugged, add survey methods? 3) If the dullness is on the left - what diagnosis is possible
suspect? 4) What further examination to offer?
1. laboratory diagnostics, radiography of OGK, CT gr. cells
2. pleural puncture after radiography and about * objective examination (percussion,
auscultation)
3. pleural effusion n / genesis
4. the examination is aimed at establishing the etiology (tank culture for the determination of
the Office, the definition
tumor markers, CT gr. Cells for the detection of tumors or metastases, laboratory diagnostics
for
detection of collagenoses, studies of pleural effusion on infectious agents, tumor
cells, office)
Task № 34
Patient 53 years old, mechanic. Coughs for about 2 months – sputum in small volume (up to a 15 ml).
Clinical blood test: L – 11,2x109 l, Hb – 120 g/l, Er. – 3,8х1012/l. Percussion – without changes.
Auscultatory – when coughing on the left in the upper parts wheezing are heard.
Do you need a consultation?

1. diagnosis: pulmonary tuberculosis
2. Research: radiography of OGK or CT
3. Determination of MBT in sputum
4. TB specialist
Task № 35
The patient was taken from the scene of incident after falling from the 3rd floor to the right side.
Objectively in the patient: aphonia, lag of the right half chest when breathing, BR – 30–32 per
minute. Percussion: box shade on the right. What was the patient's diagnosis and what were the
tactics of treatment of this patient?
1. closed chest injury on the right, complicated by hemopneumothorax on the right
2. rupture of the right lung
3. anesthesia, drainage of the pleural cavity
4. radiography of OGK, CT, bronchoscopy
5. lung suturing, with large volumes of lesion, lung resection, pleural drainage
cavities with Bulau
Task № 36
The patient is 43 years old, complains of intermittent shortness of breath, progressive weakness,
varicose veins of the neck and upper extremities. From the anamnesis ill for about 3 months, the
condition gradually worsened. The chest radiography revealed an enlargement of the anterior-
superior interstitium. What disease can be suspected? What complications of the underlying disease
can be suspected? What are the tactics of examination of this patient?
1) Establish a preliminary diagnosis.

Superior vena cava compression syndrome
CT of the chest, phlebography
3) What complications may be suspected.
Acute thrombosis with the rapid development of acute heart failure.
4) Patient treatment tactics.
Symptomatic treatment: oxygen therapy . Dexamethasone - 16-32mg \ day in \ in 7 days, then
gradual dose reduction. Loop diuretics
Etiotropic therapy:
1) radiotherapy of the mediastinum in urgent order - the method of choice in the case of most
neoplasms;
2) for chemosensitive neoplasms, the treatment of choice is chemotherapy, sometimes
additionally apply radiotherapy;
3) stenting of the superior vena cava; appointment is mandatory after the procedure
anticoagulant therapy.
With benign tumors and mediastinal cysts, in case of compression of vital
formations of the mediastinum. Large blood clot
Task № 37
A 56-year-old man complains on obstruction of solid and liquid food, pain and vomiting while eating.
He fell ill during the last two weeks, when he mistakenly drank 9 % vinegar during alcohol abuse, but
did not seek medical help immediately. What is the patient's diagnosis and what are the tactics of
treatment examination?
Establish a clinical diagnosis.

Chemical burn of the esophagus
Additional examination methods.
X-ray contrast research methods (two or three water soluble compounds -
cardiotrust, triambrin, verographin), CT OGK.
Possible complications.
Cicatricial deformities and strictures of the esophagus in places of burns, ulcerative necrotic
esophagitis,
bleeding, perforation of the esophagus.
Tactics of treatment of the patient.
In the acute period of treatment is carried out in the intensive care unit - removal of toxin,
providing
free breathing, detoxification, analgesia, desensitization, antimicrobial
prevention, inhibition of gastric secretion.
In the latent period - prophylactic (early) gulping of the esophagus, medication
support (proteases, corticosteroids, antacids, antispasmodics), HBO.
In the period of stenosis and late complications, late esophageal bougienage or
surgical treatment according to indications.
Methods of surgical treatment.
gastrostomy
Gastroejunoanastomosis
local esophagoplasty
Total (subtotal) esophagoplasty
segmental esophagoplasty
Task № 38
The patient 49 years old with complaints of difficulty swallowing water and food, pain when
swallowing behind the chest. Ill for one year. At EFGDS the endoscope hardly passes to the lower
part of a gullet, the mucous membrane is not damaged. CT chest organs revealed a round neoplasm
up to 6 cm in diameter within the muscular layer of the lower esophagus; the lymph nodes of the
interstitium are not enlarged. What is the most probable diagnosis and what are the tactics of a
general practitioner after consulting this patient?

esophageal leiomyoma
Differential diagnosis.
Lipoma, fibroma, angiomas, cancer of the esophagus, gastrointestinal stromal tumor (GIST),
esophagus diverticulum, parietal placed objects of the esophagus.
EFGDS with biopsy, fibrogastroscopy with biopsy.
Pylorospasm, esophageal diverticulum, dysphagia 4st., Cachexia.
5) Possible methods of surgical treatment.
Op. tumor nucleation, op. Garlock
Task № 39
The 42-year-old patient was hit in the stomach by a steering wheel during a car accident. Complains
shortness of breath, chest pain, palpitations, heartburn and nausea. On the radiograph of OGK
standing - displacement of the interstitium to the right, the left dome of the diaphragm is not clearly
visualized, inhomogeneous darkening of the left hemithorax to the level of the second rib with
multiple fluid levels. What is the most probable diagnosis and treatment tactics?
Traumatic diaphragmatic hernia (or a different diaphragm rupture) of the left dome
diaphragms with prolapse into the chest cavity of the intestine).
Differential diagnosis (with relaxation).
Chylothorax, pneumothorax, pneumogematoraks, acute pleural empyema, peritonitis.
CT OGK, diagnostic pleural puncture.
Pinching of organs that have fallen into the pleural cavity, pleuro-pulmonary shock, cardio-
vascular and respiratory failure, bleeding, peritonitis.
Methods of surgical treatment.
The defect is sutured with separate sutures from non-wetted material after erection
abdominal organs. Depending on the nature of the injury, surgery begins with laparo- or
thoracotomy.
Task № 40
The patient, 49 years old, after hypothermia became acutely ill with fever to 41 ºC, chest pain on the
right, vomiting with sputum with a foul odor. Objectively: the general condition is severe,
temperature – 39 ºC, pronounced signs of purulent intoxication and respiratory failure.
Radiologically: against the background of massive darkening of the upper and middle lobes, cavities
of different sizes with a horizontal liquid level are determined.

lung gangrene
The study of sputum and lavage waters of the bronchial tree (bacteriological with
antibiogram,
cytological).
General analysis of blood, urine.
Biochemical blood test (protein i of its fraction).
Immunogram.
Fibrobronchoscopy.
Evacuation of the contents of purulent cavities: - naturally through active rehabilitation
tracheobronchial tree repeated fibrobronchoscopy, aspiration through the endobronchial
catheter, instillation of therapeutic mixtures in microtracheostomy, aerosol inhalation; -
transthoracically by repeated punctures or external drainage of peripherally located
cavities.
Adequate antibacterial (drugs of choice are amoxicillin / clavulanic acid
(clavulanate), CS II generation (cefuroxime), PX II generation (ciprofloxacin) or respiratory
FH (gatimak, gatibact), thienam
Detoxification therapy (heavy drinking up to 2-3 liters per day is recommended (in the
absence of
contraindications): linden, raspberry tea, infusions of shipsya, juices, fruit
drinks). Intravenously
neogemodesis, isotonic sodium chloride solution, 5% glucose solution are injected dropwise)
Immunocorrection (under the control of the immunogram): - active - staphylococcal toxoid
according to the scheme; -
passive - globulins, hyperimmune plasma; normalization of general and pulmonary reactivity
levamisole,
thimalin, diuciphone, T-activin
Elimination of deviations of homeostasis (oxygen therapy, correction of anemia,
hypoproteinemia, acidosis,
microcirculatory disorders).
Desensitizing, anti-inflammatory therapy, regulation of protease activity: antihistamines,
non-steroidal anti-inflammatory drugs, protease inhibitors, antioxidants.
4.) indications and contraindications for surgical treatment.
Indications for surgery:
- pulmonary hemorrhage of the II-III century;
- progression of the process against the background of active and adequate therapy
- intense pyopneumothorax, cannot be eliminated by drainage of the pleural cavity;
- the inability to exclude a suspicion of a malignant tumor.
Contraindications:
decompensation of vital systems in terminal stages,
bicuspid purulent destruction in the lungs,
concomitant incurable malignant tumors
5.) possible complications of the course of their prophylaxis?
pulmonary hemorrhage; pulmonary insufficiency, chronic pulmonary heart, sepsis, education
purulent foci in distant organs . Prevention timely treatment, vaccination against
influenza and Streptococcus pneumoniae combined vaccines (bronchomunal,
ribomunil), elimination of the focus of infection
Task № 41
The patient is 38 years old, came with complaints of cough with purulent sputum 150 ml. per day,
hemoptysis, periodic increase in temperature to 38 ºС, decreased appetite, general weakness. Ill for
10 years, exacerbation of the disease in spring and autumn. Objectively: pallor, mild acrocyanosis,
thickening of the nail phalanges of the fingers. Auscultatory: wet rales under the left shoulder blade.
On radiographs - enlargement of the root of the lung, the severity and cellularity of the pulmonary
pattern on the left.

Bronchiectatic disease. Bronchiectasis of the lower lobe of the left lung.
Chest x-ray in 2 projections,
ECG, general blood and urine tests, biochemical blood tests (coagulogram, protein
fractions), Spirography, pneumotachometry, FBS
General sputum analysis Sputum analysis for mycobacteria
If necessary, special radiological techniques (SKT, SKT with iv
contrasting), computed tomography
Bacteriological examination of biological substrates (sputum, punctate, wash water and
etc.)
Bacterioscopic examination of biological substrates,
Cytological examination of biological substrates.
Serial angiopulmonography makes it possible to see the anatomical changes in the vessels of
the lungs.
3.) directions of conservative treatment.
• sanitation of the bronchial tree, removal of purulent bronchial contents and sputum -
The most important therapeutic measure. It is carried out using instillations through a nasal
catheter.
(method of intratracheal washing) or with bronchoscopy, introducing therapeutic solutions of
antiseptics
(10 ml of 1: 1000 solution of furatsilina, 10 ml of 1% solution of dioxidine, etc.), Mucolytics
(mucosolvin, acetylcysteine - 2 ml of a 10% solution). To facilitate sputum discharge
bronchodilators are recommended (especially before positional drainage, chest massage
cells).
• sanitation of upper LH (consists in the thorough treatment of teeth, chronic tonsillitis,
pharyngitis, diseases of the sinuses, reduces relapses of exacerbations of BEX, increases the
overall
patient reactivity).
• exercise therapy, massage, breathing exercises, physiotherapy
4.) indications and contraindications for surgical treatment.
Limited BY (within individual segments or lobes of the lungs) without severe bronchial
obstruction Resection of the lung eliminates the focus of chronic infection. Significant
improvement
conditions or complete recovery after lung resection is noted in 97% of patients;
Not the effectiveness of conservative treatment.
• COPD, and chronic pulmonary heart disease,
• Amyloidosis of the kidneys with renal failure.
5.) possible complications of the course of their prophylaxis?
Complications: pulmonary hemorrhage; bronchial obstructive syndrome, pulmonary failure,
chronic pulmonary heart, pleural cavity pathology (spontaneous pneumothorax, empyema
pleura); pathology of lung tissue (abscess and gangrene, cirrhosis) sepsis extrapulmonary
processes (ulcer
stomach and duodenum, amyloidosis) .
Prevention timely treatment, vaccination against influenza and Streptococcus pneumoniae,
combined vaccine preparations (bronchomunal, ribomunil), elimination of the focus of
infection.
Task № 42
A 45-year-old patient was hospitalized with complaints of cough with purulent sputum up to 200 ml
per day with an unpleasant odor, pain in the right half of the chest, fever up to 38 ºC. Ill for two
weeks. On examination: shortening of the percussion pulmonary sound under the right shoulder
blade, there – weakened vesicular respiration

Acute abscess of the lower lobe of the legal lungs, moderate degree, stage of heat and
rejection
necrotic masses.
acute phase indicators: sialic acids, seromucoid, fibrin, α second γ - globulins. • analysis
sputum: purulent with an unpleasant odor, when standing, it is divided into three layers: the
bottom is fragile
sediment (pieces of lung tissue and Dietrich's crust), the middle layer is cloudy, liquid, the
upper layer is
mucopurulent, foamy. Microscopy - large numbers of leukocytes, elastic
fibers, crystals of hematoidin, fatty acids. X-ray examination of OGK in two
projections. In the diagnosis of cavity formation of the lungs, the leading role belongs to
radiation
research (radiography, fluoroscopy, tomography). ECG, bronchoscopy.
Antibiotics of choice for lung abscess are: 2.4 g amoxicillin / clavulanic acid
with an interval of 6:00 with the subsequent transition to oral administration of 625 mg with
an interval of 6-8 hours or
ampicillin / sulbactam - intravenously; possible use of cefaperazone / sulbactam
intravenously or a combination of amoxicillin at 0.5-1.0 g with an interval of 8:00 and
metronidazole at 0.5-
1.0 g with an interval of 8-12 hours intravenously followed by oral administration (stepwise
therapy). Alternative treatment regimens include: a combination of lincosamides -
clindamycin 600
mg with an interval of 6-8 hours with the subsequent transition to oral administration - 300
mg with an interval of 6:00 s
aminoglycoside or CS III-IV generations (cefotaxime 2 g at an interval of 8:00, ceftriaxone 2
g
with an interval of 12-24 hours;
a combination of FC II-III generations (ciprofloxacin, levofloxacin) with
metronidazole; monotherapy
PF IV generation - moxifloxacin (400 mg 1 time per day, followed by transition to reception
inside - 400 mg once a day) or carbapenems - meropenem or imipenem (1-2 g with an interval
of 8:00).
The duration of ABT is determined individually, but, as a rule, it is more than 3-4
weeks.
Infusion therapy:
4.) Indications and contraindications for surgical treatment
contraindications:
pulmonary hemorrhage
the location of the abscess in the projection of the main vessel, heart,
hemocoagulation disorders.
indications:
massive as well as repeated pulmonary hemorrhages
chronic abscesses;
purulent process progression against the background of intensive therapy with the use of
"small"
Surgery
the inability to exclude a malignant tumor.
III degree respiratory failure,
bilateral lung damage,
cardiac decompensation
paresis, paralysis,
concomitant inoperable malignant tumors,
5) possible complications of the course and their prevention?
pyopneumothorax;
mediastinal and subcutaneous emphysema;
pleural empyema;
pulmonary hemorrhage;
sepsis
metastatic brain abscess.
Prevention is the timely diagnosis and treatment of the underlying disease.
Task № 43
A 37-year-old patient with bilateral hydrothorax had multiple pleural punctures on both sides. After
the next puncture there is a worsening of the condition, fever up to 39 ºC, chest pain. The next day,
the attending physician obtained pus on the right pleural puncture.

Right-sided acute pleural empyema
2.) examination methods need to be appointed additionally?
Survey radiography in two projections.
Pleurography.
Thoracoscopy
Examination of punctate from the pleural cavity and sputum.
3) Directions of conservative treatment.
Diagnostic pleural puncture in the 7th intercostal space in the back axillary line.
With limited empyema, puncture at the point due to chest x-ray in
direct, lateral, right or left oblique projections.
Thoracocentesis with drainage of the pleural cavity.
Active aspiration.
Lavage of empyema cavity with Decasan antiseptic solutions using lavage
tracheobronchial tree - in a volume of 100 ml. (Up to 3 times a day).
Possible introduction of Dekasan:
through microtracheostomy - 25-50 ml 1-2 times a day;
through a transnasal catheter - 5-10 ml once a day;
ultrasonic inhalation method - 5-10 ml 1-2 times a day;
If conservative treatment will be ineffective.
With the transition of the process into a chronic form, that is, with the existing residual
capacity
cavities.
In the formation of bronchial norici
5) What are the possible complications of the course, their prevention?
Bleeding - intrapleural or pulmonary due to arrosion of the vessel wall.
The formation of bronchial or thoracic fistula.
Transition to the chronic stage - the formation of a residual cavity as a result of the
development of processes
stiffness, pneumosclerosis.
Aspiration of the contents into the respiratory tract, asphyxia, sepsis.
Timely and adequate treatment
Task № 44
A 32-year-old patient was hospitalized with complaints of fever up to 39 ° C, chest pain, bad breath,
wet cough with purulent sputum in small quantities. The disease is associated with hypothermia 5
days ago, the patient became acutely ill with a fever to 41 ºC 1) Formulate a

Acute lung abscess, moderate degree, stage of heat and rejection of necrotic masses.
2.) examination methods need to be appointed additionally?
acute phase indicators: sialic acids, seromucoid, fibrin, α second γ - globulins. • analysis
sputum: purulent with an unpleasant odor, when standing, it is divided into three layers: the
bottom is fragile
sediment (pieces of lung tissue and Dietrich's crust), the middle layer is cloudy, liquid, the
upper layer is
mucopurulent, foamy. Microscopy - large numbers of leukocytes, elastic
fibers, crystals of hematoidin, fatty acids. X-ray examination of OGK in two
projections. In the diagnosis of cavity formation of the lungs, the leading role belongs to
radiation
research (radiography, fluoroscopy, tomography). ECG, bronchoscopy.
Antibiotics of choice for lung abscess are: 2.4 g amoxicillin / clavulanic acid
with an interval of 6:00 with the subsequent transition to oral administration of 625 mg with
an interval of 6-8 hours or
ampicillin / sulbactam - intravenously; possible use of cefaperazone / sulbactam
intravenously or a combination of amoxicillin at 0.5-1.0 g with an interval of 8:00 and
metronidazole at 0.5-
1.0 g with an interval of 8-12 hours intravenously followed by oral administration (stepwise
therapy). Alternative treatment regimens include: a combination of lincosamides -
clindamycin 600
mg with an interval of 6-8 hours with the subsequent transition to oral administration - 300
mg with an interval of 6:00 s
aminoglycoside or CS III-IV generations (cefotaxime 2 g at an interval of 8:00, ceftriaxone 2
g
with an interval of 12-24 hours;
a combination of FC II-III generations (ciprofloxacin, levofloxacin) with
metronidazole; monotherapy
PF IV generation - moxifloxacin (400 mg 1 time per day, followed by transition to reception
inside - 400 mg once a day) or carbapenems - meropenem or imipenem (1-2 g with an interval
of 8:00).
The duration of ABT is determined individually, but, as a rule, it is more than 3-4
weeks.
Infusion therapy:
4.) Indications and contraindications for surgical treatment
contraindications:
pulmonary hemorrhage
the location of the abscess in the projection of the main vessel, heart,
hemocoagulation disorders.
indications:
massive as well as repeated pulmonary hemorrhages
chronic abscesses;
purulent process progression against the background of intensive therapy with the use of
"small"
Surgery
the inability to exclude a malignant tumor.
III degree respiratory failure,
bilateral lung damage,
cardiac decompensation
paresis, paralysis,
concomitant inoperable malignant tumors,
5.) possible complications of the course and their prevention?
pyopneumothorax;
mediastinal and subcutaneous emphysema;
pleural empyema;
pulmonary hemorrhage;
sepsis
metastatic brain abscess.
Prevention is the timely diagnosis and treatment of the underlying disease
Task № 45
A 35-year-old man was hit by a car while crossing the street. On examinations there was deformity
on the 1/ 3 of both legs. He was unable to stand. What could be the diagnosis? Complete the clinical
picture according to the diagnosis.
Preliminary diagnosis: a fracture of the middle third of the diaphysis of the right and left large
and fibular
bones.
Clinic: acute pain, impaired function, deformation of the axis of the legs (depending on the
direction
fragments of fragments), protruding under the skin of the end of the distal or proximal
fragment. Shin
on the damage side may be shorter. Active movements are impossible, passive significantly
limited due to exacerbation of pain. Swelling at the fracture level. Palpation: acute pain on
deformation height, there is pathological mobility, crepitation of fragments.
Differential diagnosis:
With fractures with displacement, function is lost, significant pain arises, circular
swelling at the fracture level, the presence of protrusion of pathological debris; whereas when
bruising swelling is located in the city of the action of the traumatic agent, are absent
radiological changes in the bones.
With fractures without displacement, there is an available positive symptom of pathological
mobility and
exacerbation of pain with axial pressing on the lower leg, which does not happen with bruises.
Treatment of diaphyseal fractures of the leg bones without displacement, subperiosteal
fractures and
bone cracks are treated by mobilization with a cast gypsum dressing tarmin for 2-3 months.
Subperiosteal fracture 3-4 weeks.
Fractures with a transverse plane, notches, when there is no fragmentation after matching
propensity for secondary vision - one-time closed comparison with immobilization
limbs chased with a plaster cast for a period of 3-3.5 months. X-ray control after 2 months,
know the cast, to assess the nature of the fusion, and then again apply the cast to the knee
joint,
with permission for dosed static load. After 3 months, plaster + X-ray is removed
control, rehabilitation courses. Return to physical work after 4-5 months.
In case of fragmentation fractures, skeletal traction is used for treatment. Metal osteosynthesis
with
knitting needle, compression plates, Tauri beam Klimov. After 3-6 months. without removing
the skeletal
put gypsum, after curing it remove the needle, after 2.5 months
from gypsum.
Task № 46
A 70-year-old woman fell at home, and complaints of severe pain of her right hip joint, and unable to
use her right lower limb. She was taken to the hospital and admitted in emergency department. After
examination and X-ray examination was diagnosed with a fracture of the neck of the right femur.
What is the clinical presentation of the injury?
Clinic: pain in the hip, lack of active movement, loss

limb function.
Abduction fracture: a slight displacement of the axis of the lower fossil inward is
characteristic
the top of the greater trochanter on the Roser-Nelaton line, there is no relative shortening
limbs. The pressure of the fifth along the axis of the lower limb or tapping on it causes
exacerbation of pain in the hip joint.
Adduction fracture: injured limb rotated outward, has significant
relative and functional shortening, the top of the greater trochanter is higher
Roser-Nelaton lines, passive movements and loads along the limb axis exacerbate pain in
the hip joint. Femoral pulsation under the inguinal may be available
Task № 47
Establish the diagnosis on the basis of the following signs: 1) pain on the knee joint, 2) limited joint
movements 3) increased circumferential size of the joint, 4) the symptom of "runner’s knee". How to
check (examine) for these clinical symptoms?
Acute and chronic diseases, sports and everyday injuries of the knee joint
provoke balloting of the patella, indicating accumulation
intraarticular fluid is above normal. The grounds for the "floating" cups are
pathological conditions of the knee structure, provoke an increase in intraarticular
effusion, namely: Osteoarthrosis of the knee, purulent arthritis, dropsy of the joint
(hydrarthrosis), acute mechanical injury, fractures of the elements of visual injury. External
injuries
and inner meniscus, anterior and posterior cruciate ligaments, synovial capsule
joints entail a symptom of balloting of the patella. First sign
knee dysfunction is a pain symptom whose intensity
closely related to the volume of fluid. Up to 15 ml, the pain appears in a few days, and with
more - intense, acute in nature immediately after the fact of the injury.
Limited movements cannot be overlooked. Impairment of extensor function
movements, the formation of contracture in a bent joint. Active movement and
reliance on a sore leg give severe soreness. Forms of the knee structure
smoothed with an effusion of more than 15 ml, the knee increases in volume compared with
healthy foot. For diagnosis, puncture of the knee joint is used to
determine the nature of the fluid. X-ray of the knees in two projections makes it possible
confirm the fact of fractures. Also use arthroscopy - minimally invasive
interventions with medical and diagnostic intentions. Additionally, CT is prescribed,
MRI, ultrasound of the knee. After confirmation of the diagnosis and
differential diagnosis appoint a list of therapeutic measures:
● extraction of fluid from the joint cavity by puncture or arthroscopic methods;
● use for procedures novocaine and antiseptics for washing;
● immobilization of the knee with a span for up to 2 weeks
● strict adherence to the state of complete rest of the affected structure;
● therapy of cause ballot;
● therapeutic physical culture (LFK), starting from the moment of immobilization;
● physiotherapeutic treatment a week after trauma.
Task № 48
During the high jump, the athlete felt severe pain in the heel. On examination, there is swelling in
the posterior part of the ankle joint, no active plantar flexion of the foot, normal X-Ray of the foot.
What is the most probable diagnosis?
Diagnosis: Closed rupture of the Achilles tendon.

Rationale: damage mechanism (during high jump),
severe pain in the calcaneal tubercle, swelling in the posterior surface
of a joint that is not accessible, active plantar flexion of the foot impossible gives us
grounds to establish a preliminary diagnosis of closed Achilles tendon rupture.
Diagnosis: Ultrasound is used to diagnose Achilles tendon rupture.
research and / or magnetic resonance imaging. MRI will also help with diagnosis.
Achilles tendon sprains.
Treatment: in the treatment of sprains (Achilles tendon), a fixative is used
Longeta. In case of rupture of the Achilles tendon, surgical intervention is indicated.
Task № 49
Write the diagnosis of the injury basis of the following signs: • positive "stuck heel" symptom, leg
shortening, • deformity on the middle third of the leg. Write other additional specified clinical
picture.
Complete the indicated clinical picture.

Preliminary diagnosis: fracture of the middle third of the tibia diaphysis.
Clinic: acute pain, impaired function, deformation of the axis of the legs (depending on
displacement of fragments), protruding under the skin of the end of the distal or
proximal fragment. The lower leg on the side of the lesion may be shorter. Active
movements are impossible; passive movements are significantly limited due to exacerbation
of pain.
Swelling at the fracture level. Palpation: acute pain at the height of deformation, there is
pathological mobility, crepitation of fragments.
Task № 50
An elderly man fell on the street, hit his left shoulder and felt sharp pain in the upper third of the
shoulder. He supported the injured left arm with his healthy arm by the elbow pressed close to the
body. Name the probable diagnosis. What are the possible complications?
What is the probable diagnosis? Indicate possible complications.

Diagnosis: Fracture of the surgical neck of the humerus.
Complications: contracture of the shoulder joint, abnormal fusion, avascular necrosis of the
head
humerus, nonunion of the surgical neck of the humerus
Task № 51
After falling from a height of 3 meters on a straightened leg, the man complaints of severe pain in the
heel and unable to stand on his feet. What are the possible diagnosis? Write the radiological
investigation for the injury. What other injuries can be at the specified mechanism of an injury? What
clinical and radiological signs in these injuries?
Diagnosis: Fracture of pyatovikkistok.

X-ray signs:
1. Damage to the continuity of the contour of the cortical layer.
2. Appearance of the fracture line in the vision of the dark.
3. Kutovadeformation osikistki.
4. Appealing to the core of the ossicular nucleus.
5. Employment
Spinal injuries.
Clinically: pain that may first be spilled and then gradually limited to a zone
damage, increased pain when trying to raise straightened legs, and the most soreness
occurs when bending to the healthy side, injuries of the chest-lumbar spine can
manifested by the clinic "acute abdomen" ("pseudo-abdominal syndrome" - pain in the
abdomen
and even a certain tension of the anterior abdominal wall), which is explained by irritation
solar plexus and retroperitoneal hematoma. In case of damage to the spinal cord -
neurological symptoms.
X-ray signs: fracture of the lower thoracic and lumbar spine
Task № 52
The skier complaints of severe pain of the right leg after fall when coming down from the mountain
and sustain injury on the lower third of the right leg. The foot is sharply rotated outwards. What kind
of fracture can we talk about? What types of displacement can be in this case? What kind of
shortening can there be?
Dupuytren's fracture.
Type of displacement: fracture of the medial ankle with lateral displacement of it, the external
bone
they extend in length, in some cases in width.
Type of shortening: relative
Task № 53
An elderly man was admitted to orthopedic department with a provisional diagnosis of left medial
femoral neck fracture. What will be the clinical presentation during the examination of the patient?
the length of the limbs, palpation? which radiological signs that will confirming the diagnosis?
The patient complains of pain in the area of the hip joint, which is localized under the puparta
ligament, loss of support of limb. Pain aggravated by palpation. Ending
rotated outward and shortened (there is a relative shortening).
passive and active movements, as well as with axial load (tapping on the heel or on the axis
cervix) - the pain intensifies sharply. The symptom of a “sticking heel” is positive - the patient
does not
able to lift and hold a straightened leg, so he bends it in the hip and
knee joint, which leads to a slip of five on the surface.
On the x-ray of the hip joint, a fracture line is visible in the femoral neck, as well as
displacement of fragments
Task № 54
During cars collision one of the passenger right knee struck against the front seat. During
examination the patient complaints of a severe pain around the right hip joint. The leg is in a passive
position, flexed at the knee and hip joints. Restricted movements in the joints. Name the possible
diagnosis of the injuries. What X-ray will be ordered to confirm the diagnosis.
Diagnosis: Back hip dislocation.

X-ray changes: spatial mismatch of the articular surfaces of the joint bones
(femoral head, lunate surface of the acetabulum of the pelvic bone),
expansion of the joint space.
Task № 55
A young man fell on the street and hit his left elbow. During examination elbow joint deformity
noted, and the olecranon process posteriorly displaced. The arm bent at an angle of 110°, restricted
joint movements. What are the possible diagnosis and methods of treatment?
Diagnosis: fracture of the ulnar process.

Tactics of treatment:
Conservative treatment: for fractures of the ulnar process without displacement or when
diastasis between
fragments up to 3 mm.
With a distance between fragments of 5 mm, a simultaneous reposition should be performed.
fragments and plaster immobilization of the shoulder and forearm to the base of the fingers in
position
extension at an angle of 100-120 ° in the elbow joint and in the middle position between
supination and
pronation for up to 4-6 weeks.
With a discrepancy of fragments of more than 0.5 cm is an indication for surgical treatment -
osteosynthesis
fragments of the ulnar process with the obligatory elimination of interposition and restoration
the tendon of the triceps brachii
Task № 56
The patient enters the doctor's office, holding the elbow joint of the right hand with his left hand,
which is tightly pressed to the torso. The patient's head is tilted to the right. Complains of severe pain
in the right shoulder joint. What kind of damage can we talk about? Name the clinical signs of this
injury. Provide X-ray examination data. Indicate possible complications
Give the data of the X-ray examination. Indicate possible complications.

Traumatic shoulder dislocation (posterior) Clinical signs: sharp pain, lack of movement
shoulders that occur immediately after injury. Forced position: shoulders lowered to
side of the lesion, the patient's head is tilted in the same direction. The patient is trying to
create peace
limbs, carefully supporting it with a healthy hand. In muscular and obese people, deformation.
the shoulder girdle and shoulder joint are leveled by soft tissues. In this case, it is detected
when
Marx symptom test: on both sides they press symmetrically on both shoulders and on the
outside
shoulder joint, with the finger on the affected side of the distal acacromal process
deepens more than on the healthy side, which indicates a dislocation of the shoulder. Active
movements
in the joint are absent or sharply hindered. When trying passive movements (raise hand
patient, lead or take her away) note the elastic fixation of the shoulder - a symptom of "spring
resistance. " On the roentgenogram (direct and axillary projections) - displacement of the head
the humerus relative to the posterior articular cavity, located under the
clavicle. Complications:
injury to the brachial plexus (paresthesia, paresis, paralysis), muscle breakdowns, fracture of a
large tubercle,
fracture
Task № 57
During a road traffic accident, a man was crushed by a fallen heavy box. After rescued from the
cargo, He complains of severe pain in the right half of the chest and difficulty in breathing. He was
taken to hospital. On examination – breathing. In auscultation breathing sound in the lower parts of
the right lung. What is the possible diagnosis? What are the clinical features of this injury? What are
the possible complications ?and principles of treatment of this injury
Right-sided fracture of ribs, accelerations by hemopneumothorax. Clinic: a symptom of

"dangling
inspiration ”, swelling at the fracture site, local pain, crepitation of fragments of the ribs
during palpation,
Complicated: pleuropulmonary shock, pleural empyema, cardiovascular
insufficiency, respiratory failure. Treatment: pleural puncture + active
drainage. According to the indications of thoracoscopy, thoracotomy - if bleeding continues.
Task № 58
A young man brought to the emergency department after fall from a height with a diagnosis of
"closed chest injury, multiple rib fractures and pleuropulmonary shock." Describe the clinical
features, palpation, auscultation and chest X-ray. Outline the treatment plan for the patient.
Clinic: most likely that the patient had a fenestrated (double) fracture of the ribs;
paradoxical breathing - with inspiratory, the lung on the side of the lesion decreases in volume
and the air from it enters a healthy lung, it spreads out from the middle, develops a left-heart
insufficiency and pleuropulpononal shock. Dyhannyapverkhneve, frequent, symptom of
"dangling
inhalation ”, pallor of the skin, sticky cold sweat, cyanosis, pain and crepitus with
palpations, traces of trauma on the chest, pinnacle AT. Radiography - fissured fracture of the
ribs.
(Overview and side projection).
Treatment: anesthesia (narcotic analgesics, block according to Vishnevsky,
epidural anesthesia, the use of external fixators (Silin tire, plastic tires),
osteosynthesis with staples or metal plates. If a float valve
is the chest - extension over the sternum, loads 1.5-3 kg for 2-3 weeks
Task № 59
The young man fell on the street and hit his left shoulder. He complains of left shoulder joint pain
and restriction of movement in this joint. On examination there is a step deformaty on middle third
of the clavicle, elastic mobile up and down when pressing with the finger, tender on palpation. What
is the diagnosis? What is the name of the symptom characteristic of this injury?
Acromial dislocation of the clavicle. key symptom
Task № 60
Treatment of a scapular fracture is carried out by the method of constant skeletal traction. Describe
the extension system and the position of the upper limb. The amount of weight used and how long
will skeletal traction be applied.
The needle is held along the ulnar process and the upper limb should be in the abduction
position in
shoulder joint up to 90 ", posterior deviation up to 10" and flexion in the elbow joint up to 90
". Traction from
1.5 kg to 3.5-4 kg. Skeletal traction lasts 4 weeks, after which it is removed, the limb is laid
on a wedge-shaped pillow and conduct a course of physical therapy lasting 2
weeks. Operability
restored 2 months after injury
FUNDAMENTAL ISSUES OF SURGERY STATION III
Task 1
A 57-year-old man complains of pain in the right leg, which occurs when walking, can go up to 150
m without stopping. Objectively: the skin of the right foot and toes is pale, its temperature is
low. The pulsation over the femoral artery is satisfied, on the right popliteal artery - no.
1) What disease should be suspected?
Obliterating atherosclerosis of the vessels of the lower extremities, occlusion of the
patellofemoral segment on the right.
2) With what diseases it is necessary to carry out differential diagnosis?
Obliterative endarteritis; obliterating thromboangiitis; Raynaud's disease; sciatica; diabetic
neuropathy; Schmorl's hernia, nonspecific aortoarteritis.
3) What instrumental research methods will confirm the diagnosis?
Dopplerography; aortoarteriography; rheovasography.
4) What are the tactics of treatment of this patient?
Surgical treatment: stenting or shunting of the right popliteal artery.
5) What complication can this patient have if he does not receive proper medical care?
The patient may have acute ischemia of the right lower extremity as a consequence of
obliteration or embolization by atherosclerotic plaque, which will lead to gangrene of the
right lower extremity and its amputation.
Task 2
A 67-year-old patient with a history of atrial fibrillation suddenly developed burning pain in her
left leg and foot. Objectively: shin and foot pale, cold to the touch. Pulsation over the popliteal
artery and arteries of the foot - no.
1) What is the most likely diagnosis?
Embolism of the left popliteal artery.
2) What are the tactics of a general practitioner after consulting this patient?
Immediately refer the patient to a vascular surgeon for emergency surgery in the next 6
hours.
3) Should a general practitioner prescribe auxiliary diagnostic methods the next day?
Diagnosis should be performed in the first hours. It is not advisable to perform diagnostic
methods the next day, because the patient will already develop gangrene of the lower
extremity.
Treatment: emergency surgery, most appropriate in the first 6 hours. to save the limb. An
embolectomy is performed: with a Fogarty balloon catheter, a vascular ring, a vacuum
aspirator, a balloon probe by retrograde lavage of the arteries.
5) What awaits the patient if he does not receive proper treatment in time?
If you do not immediately perform emergency surgery, the patient will develop gangrene of
the left lower extremity.
Task 3
The patient is 53 years old, hospitalized with complaints of edema and pain in the right thigh and
lower leg. Ill for 2 days. On examination, the skin of the right lower limb is bluish, tense, shiny. The
circumference of the right leg and thigh is greater than the left by 6 cm. The pulsation over the main
arteries is preserved. With what diagnosis was the patient admitted and what are the tactics of
treatment of this patient?
1) What is the diagnosis of this patient?
Ileofemoral venous thrombosis of the right lower extremity.
Chronic venous insufficiency; limb injury; superficial vein thrombosis; hematoma in the
muscles of the thigh or lower leg; lymphangitis; focal cellulite; acute arterial
thrombosis; acute arterial embolism.
Ultrasonography, phlebography.
Conservative treatment.
Bed rest with elevated limb position for 14 days.
Anticoagulants: low molecular weight heparin, rivaroxaban, dabigatran,
apixaban. Thrombolysis topically, using a catheter.
Refer the patient to a vascular surgeon.
Task 4
A 54-year-old man, 40 years of smoking, complains of impotence and pain in both lower
extremities, which occurs when walking, can go 100 m without stopping. Objectively: the skin of
both lower extremities is pale, cool to the touch. Pulsation over the main arteries of the lower
extremities is absent.
1) What syndrome can be suspected?
Lerich's syndrome.
Rheovasography; dopplerography; aortoarteriography.
3) To which doctor's specialty should a general practitioner refer after consulting this patient?
To the vascular surgeon.
4) Is urgent surgical treatment indicated for this patient?
Urgent surgery is not indicated for this patient. Because there is no threat to life, and Lerish
syndrome is a chronic disease (atherosclerosis of the bifurcation of the iliac
arteries). Surgery is planned.
5) What surgical treatment is indicated for the patient?
The patient is shown endarterecomia with prosthetics, or the imposition of a shunt between
the aorta and the peripheral artery.
Task 5.
A 34-year-old patient who works as a hairdresser complains of the presence of nodular neoplasms
in the area of the medial surface of the lower leg and thigh, a feeling of distension and heaviness in
the lower leg at the end of the working day. Notes the reduction of nodes in the horizontal position
of the lower extremities.
1) What is the probable diagnosis?
Chronic varicose veins of the lower extremities, stage of subcompensation,
2) Do I need to consult a vascular surgeon?
so
3) What instrumental research methods will the doctor suggest?
ultrasound angioscanning,
Emission computed tomography
Doppler ultrasound
Surgical: sclerotherapy, or cryostripping, or intravascular laser coagulation
Conservative: detralex, Venarus , Anavenol , Vazobral
Physiotherapeutic: therapeutic physical training, magnetic therapy,
Compression therapy: elastic bandage, or special individually selected compression stockings
complications: bleeding from the node (varices) in trauma, phlebitis, thrombophlebitis, thrombosis,
pulmonary embolism, ulcers on the lower extremities.
Task 6
A 76-year-old patient with varicose disease of the lower extremities and venous bleeding from a
varicose node in the lower third of the leg in the area of a trophic ulcer was hospitalized in the
admission department.
send to a specialized department to a vascular surgeon
2) How to perform hemostasis in the prehospital stage?
apply a gauze napkin to the bleeding site, then tie the leg tightly with an elastic bandage, put the
patient in a horizontal position so that the leg is above the torso, apply cold to the bleeding site for
15 - 20 minutes
Surgical treatment (methods below)
Me dykamentoznaya therapy.
Phlebotonics (phleboid 600, antistax, anavenol, venoruton, troxerutin, escuzan, detralex, glivenol)
Disaggregants (aspirin, trental, vasobral, doxium, curantil)
Antioxidants (vitamin E)
Anticoagulants (fraxiparin)
Fibrinolytics (nicotinic acid)
Affecting trophic processes (actovegin, solkoseril, ginkfort)
Anti-edematous (antistax)
Physical methods of treatment - alternating magnetic field, darsonvalization, pneumovibration
stimulation, massage, electrophoresis, UHF, laser therapy
4) What other complications occur with varicose veins.
bleeding from an enlarged node, phlebitis, thrombophlebitis, thrombosis, pulmonary embolism,
ulcers.
5) What operations are performed for varicose veins?
saphenoctomy (stripping). Babcock stripping probe. Intussusception stripping. Bandaging of
perforating veins according to Kokket. Feld operation in the modification of Svalev-Konstantinov,
catheter scleroobliteration, phlebectomy, crossectomy, laser ablation.
Task 7
The 68-year-old patient underwent a prostatectomy five days ago. Suffers from coronary heart
disease, hypertension, varicose veins of the lower extremities. Suddenly there was a pressing pain in
the left half of the chest with spread to the left shoulder, shortness of breath, whooping cough. On
the ECG - signs of overload of the right heart.
1) What is the most likely complication in a patient?
thromboembolism of the left pulmonary artery
2) With what diseases it is necessary to carry out differential diagnostics?
myocardial infarction, pneumonia, acute pulmonary heart syndrome, pulmonary infarction,
bronchial artery thrombosis.
Electrocardiography, Echocardiography, Ventilation-perfusion scintigraphy, Chest radiography,
Selective contrast angiopulmonography, Spiral computed tomography, Ultrasound examination of
deep veins of the lower extremities.
oxygen therapy,
to buy prednisolone collapse,
Narcotic analgesics - fentanyl, promedol, morphine are used to buy pain.
Anticoagulant therapy: heparin, fraxiparin, warfarin,
Thrombolytic therapy: streptokinase, urokinase, alteplase,
5) What is the prevention of this complication?
preventive installation of a coffee filter and preventive use of unfractionated heparin
Task 8.
The 69-year-old patient, on the 5th day after gastrectomy for cancer, suddenly felt shortness of
breath, chest pain. Objectively: tachypnea, blood pressure -90/60 mm Hg. Art., pulse - 110 beats /
min, on the ECG - signs of overload of the right heart. The attending physician suspected
pulmonary embolism.
Pneumonia, pleurisy, pneumothorax, intercostal neuralgia, chest pain, cardiogenic shock, acute
valvular insufficiency of the left heart, rupture of the interventricular septum, cardiac tamponade,
aortic dissection.
ECG: the appearance of blockade of the right leg of the His bundle, P-pulmonale, sinus tachycardia
or other arrhythmias (atrial fibrillation or flutter, extrasystole).
Echocardiography: enlargement of the right ventricle, the presence of blood clots in the right heart,
pulmonary hypertension,
OGK:
High standing of the dome of the diaphragm in the area of lung damage.
Hampton's symptom (Hampton's triangle) is a wedge-shaped darkening of the pulmonary field, the
base returned to the pleura (the most characteristic sign of pulmonary embolism on chest
radiography).
Dilation of the shadow of the superior vena cava due to increased pressure in the right heart.
An increase in the size of the pulmonary artery - the explosion of the second arc (pulmonary cone)
along the left contour of the shadow of the heart (Fleischner's sign).
The appearance of fluid in the pleural cavity.
Angiopulmonography: defect in the filling of the lumen of the vessel, complete obstruction of the
vessel ("amputation" of the vessel, breakage of its contrast with the expansion of the proximal
occlusion site), symptom of "dead tree"
Step 1. Perform anesthesia:
• (fentanyl 1-2 • promedol - 1 ml of 1% solution, morphine - 0.5 ml of 1% solution intravenously.
Step 2. Stop the collapse:
• dopamine - 1 ml of 0.5% solution in / in drip;
• prednisolone - 60-90 mg iv, iv;
• rheopolyglucin - 400 ml of 10% solution.
Step 3. Reducing the pressure in the small circle of blood circulation:
• theophylline - 10 ml of 2.4% solution intravenously;
• papaverine, but-spa, drotaverine - 2 ml of 2% solution intravenously, intravenously.
Step 4. Carrying out anticoagulant therapy:
• heparin - 10000-15000 IU IV, then 60 IU / kg p / w;
• fraxiparin - 0.6 ml n / w.
Treatment: Emergency embolectomy (with the help of a Fogarty catheter) a probe with a balloon at
the end is inserted under the control of radioscopy and thrombus fragmentation is performed,
followed by thrombolytics.
4) What should the attending physician do to prevent this complication?

Prevention: installation of a coffee filter and prophylactic use of unfractionated heparin and low
molecular weight heparin preparations.
5) Does the patient need to be transferred to the intensive care unit.
yes, needs to be transferred to intensive care
Task 9.
The patient, 43 years old, complains of stabbing pain and swelling of the right leg. Symptoms
worsen at the end of the working day. From the anamnesis 3 years ago she suffered from deep vein
thrombosis of the right lower extremity. On examination: the limb is pasty, increased in volume, on
the inner surface of the leg there is lipodermatosclerosis and trophic ulcer up to 3 cm in diameter.
1) What diagnosis can be suspected?
Postthrombophlebitic syndrome
Cellulite, Lymphedema (lymphedema), Compression of a vein from the outside by a tumor,
Stretching or rupture of muscles, Rupture of a synovial cyst (Baker's cyst), Thrombophlebitis of
superficial veins
1) general (clinical) blood test; 2) study of the hemostasis system coagulogram); 3) determination of
D-dimer - D-dimer is a diagnostic marker, and normally its content in plasma should not exceed
250 ng / ml 4) duplex ultrasound examination; 5) X-ray contrast phlebography.
and. Anticoagulant therapy: 5000 IU of heparin IV cap. 2 r / d 7-10 days, then 3-4 days before the
abolition of heparin is transferred to indirect anticoagulants for 3 months (Phenylin, Warfarin,
Kumadin)
b. Antiplatelet therapy: curantil 0.75 mg 3 times, rheopolyglucin 200 ml intravenously,
in. Thrombolysis (streptokinase, streptase)
d. Improvement of lymphovenous outflow: elastic bandaging of extremities and a strict bed rest
e. Chir treatment: thrombus removal; - ligation or stitching (plication) of a vein; - imposition of an
arteriovenous shunt; - installation of the coffee filter.
active lifestyle, proper nutrition, abandonment of bad habits;
compression underwear at static loadings, at surgical interventions, during pregnancy;
control of blood coagulation during pregnancy;
early activation after surgery.
observation by an angiosurgeon 2 times a year;
ultrasound examination once a year
Task 10 .
A 57-year-old woman with diabetes for more than 10 years complains of an ulcer in the heel area of
the right lower extremity and decreased sensitivity of the right foot. The pulsation over the femoral
and popliteal arteries is satisfied, over the arteries of the foot - weakened. What diagnosis should be
suspected and what are the tactics of a general practitioner after consulting this patient?
1) What is the syndrome in this patient?
Diabetic angiopathy
2) Do I need to consult a vascular surgeon?
Yes, it needs a consultation with a vascular surgeon
3) What instrumental research methods should be prescribed to the patient to decide the
tactics of treatment?
Ultrasound, angiography
Sugar-lowering therapy,
Vasodilators (Trental 5 ml in / in drops 10 days
Spasmolgon 2 ml intravenously 10 days)
Anticoagulants (fraxiparin 0.3-0.6 ml in the umbilical region)
Antiplatelet agents (aspirin, curantil, cardiomagnil)
Plasmosamine of roses (Reosobilakt 200ml 10 days)
Antioxidants (vitamin E 1 caps 1 month)
Antilipidemic (Nicergoline IV 4 mg 10 days)
gangrene
Task 11
A 67-year-old patient was hospitalized with complaints of pain in the right lower extremity and a
rise in body temperature to 39 ºC. From the anamnesis he has type II diabetes for 15 years, he does
not control blood glucose. Objectively: blood pressure - 90/60 mm Hg. Art., pulse - 130 beats /
min. Covered with sticky sweat. The limb is significantly increased in volume, there are necrotic
changes and purulent discharge in the leg and foot. Pulsation over the popliteal artery and arteries of
the foot - no.
1) What is the most likely diagnosis?
Diabetic foot syndrome
2) What are the tactics of a general practitioner after consulting this patie nt?
Hospitalization in the chorus of the department
3) Should a general practitioner prescribe a consultation with a surgeon?
So it should be
Limb amputation
5) What awaits the patient if he does not receive proper treatment in time?
If the patient does not receive proper treatment, the process will go uphill.
From the return 12

The patient went to the clinic to see a doctor with complaints of pain in the upper lip, edema, pain in
the temple. Body temperature 39 ° C. There is significant swelling of the upper lip and eyelids.
1) What is the patient's diagnosis?
Carbuncle of the upper lip
2) Tactics of the surgeon in relation to the patient?
Hospitalize to a surgeon. department
3) What treatment should be given to the patient?
Surgical treatment:
- dissection of the abscess
- drainage of the wound before the discharge of the rod.
Drug treatment:
- antibiotic therapy (cefatoxime, ceftazidime, augmentin)
- detoxification therapy. (Neogemodesis, rheopolyglucin)
- non - narcotic analgesics.
- antihistamines.
Topically: wound washing with antiseptics (dioxidine, chlorhexidine), treatment with enzyme
solutions (trypsin, chymotrypsin)
Physiotherapy: UHF, microwave, UV under effective drainage
4) What complications are possible in this case?
Complications: phlebitis, purulent meningitis, cerebral sinus thrombosis, sepsis
5) Ways of infection?
Ways of distribution (anastomosis of facial veins - v . Facialis angularis , v . Ophthalmica sup .
With veins of meninges and cerebral sinuses)
Task 13
A patient came to the surgeon with complaints of pain in the right axillary area, which is
exacerbated by movements in the right shoulder joint. Ill for three days. On examination: in the
axillary region revealed 3 dense limited infiltrates from 0.8 to 1.2 cm, which protrude significantly
above the skin with slight redness.
1) What happened to the patient?
Axillary hydradenitis. Cuts and microtraumas contribute to the infection of the sweat glands.
2) What should be the treatment tactics?
Outpatient treatment. To prevent the spread of infection, it is necessary to wipe the area around the
hearth with boric, salicylic or camphor alcohol 3-4 times a day.
Drug therapy of hydradenitis involves the use
- antibacterial agents (erythromycin, ampicillin),
- analgesics (nimesulide, meloxicam)
3) What diseases should be differentially diagnosed?
Diff. Diagnosis with a boil, however, in contrast to the boil, hydradenitis does not form the main
rod.
Also lymphadenitis, phlegmon, atheroma
4) What pathogen most often causes this disease?
The causative agent is Staphylococcus aureus
Task 14
Patient K., 26 years old, complains of pain in the right hand for 4 days. The pain first appeared in
the area of the callus on the palmar surface near the base of the second and third
fingers. Subsequently, the swelling and swelling of the back of the wrist began to increase rapidly,
and the second and third fingers were half-bent at the interphalangeal joints. The brush looks like a
"rake".
1) Your diagnosis?
Phlegmon of the second interdigital space of the right wrist
2) Clinical forms of the disease?
Clean forms - Phlegmon palmar surface - superficial, deep (tenor abscess, cellulitis gipotenora, V-
shaped abscess, cellulitis middle area (surface or deep or pidaponevrotychna and pidsuhozhylna)
commissural. Phlegmon dorsum of the hand - superficial pidaponevrotychni.
3) Therapeutic tactics?
Treatment - Phlegmon is opened with an incision at the level of the corresponding interdigital
spaces, the wound is drained and the brush is immobilized. Antibiotic therapy
4) Possible complications of this disease?
Complications . 1. The spread of the inflammatory process on the tissue of the forearm (Pirogov-
Paron fiber). 2. Purulent arthritis. 3 Radiation tendobursitis. 4. Lymphangitis. 5. Sepsis.
Task 15
A patient with complaints of pain in the left breast was hospitalized in the surgical department for 6
days. Breastfeeding. The child is 12 days old. The skin of a woman is pale. In the upper outer
quadrant of the left breast is defined by a painful seal with a diameter of 6-7 cm with softening in
the center.
acute postpartum purulent mastitis.
Depending on the spread and localization of the inflammatory process.
1. Diffuse - affects the entire breast (panmastitis).
2. Limited:
subareolar - located under the thoracic nipple;
intramammary - in the gland tissue;
in the thoracic ducts;
retromammary - between the posterior surface of the gland and the fascia of the pectoralis major
muscle.
According to pathomorphological changes.
1. Pathological lactostasis (latent stage of mastitis). 2. Serous mastitis. 3. Infiltrative
mastitis. 4. Purulent mastitis:
- infiltrative-purulent (diffuse, nodular). - abscessing (areola furunculosis, areola abscess, abscess in

the thickness of the gland, retromammary abscess). - phlegmonous (purulent-necrotic
5. Gangrenous.
galactophoritis (inflammation of the mammary ducts); - areolitis (inflammation of the glands of the
nipple ring); - superficial mastitis (inflammation is localized above the stroma of the gland directly
under the skin); - retromammary mastitis (the area of inflammation is localized under the deep leaf
of the breast capsule); with acute cancerous mastitis
Lactostasis. Mastitis-like form of breast cancer
Nodular form of breast cancer with abscess
4) Therapeutic and diagnostic tactics?
To verify the diagnosis, it is necessary to perform a puncture of the suspected abscess. Upon receipt
of pus (bakpos!), A breast abscess under intravenous anesthesia should be opened. In this case, the
most rational approach of Angerer: make a radial incision, departing from the areola 2-3 cm
Mandatory revision of the abscess cavity with a finger. After emptying the abscess, the cavity of the
latter is washed with antiseptic and drained with a rubber graduate and a tampon with ointment on a
hydrophilic hyperosmolar basis (Nitacid). Women are advised to express milk or, best of all, use a
breast pump.
Task 16
Patient M., 64 years old, after intravenous drip infusions began to complain of pain in the left
elbow. On the palmar surface of the upper third of the left forearm and the anterior inner surface of
the left shoulder along the course of the subcutaneous vein there is hyperemia of the skin,
compaction and sharp pain in the venous wall.
post-injection phlebitis

Varicose veins
The differential diagnosis should be made first of all with a postthrombophlebitic syndrome. It is
necessary to exclude compensatory varicose veins due to compression of the iliac veins by tumors
emanating from the abdominal cavity, pelvis, epigastric tissue, congenital diseases - Parks-Weber
and Klippel-Trenone syndromes.
4) What treatment will you prescribe?

General measures. The initial steps in any phlebitis are to stop the infusion and remove the catheter
(or replace it with a new one if the patient is hemodynamically unstable). The affected limb is
recommended to give a high position in order to improve blood flow and reduce the inflammatory
response. Cold is applied to the inflamed area.
Drug correction. Aimed at preventing the spread of the process to the deep segments, reducing
inflammation, improving blood flow and relieving pain. Use anticoagulants, nonsteroidal anti-
inflammatory drugs, angioprotectors. On the affected area apply bandages with heparin ointment
and NSAIDs, after the abatement of acute events - warming compresses.
Surgical methods. Surgical treatment is necessary for purulent thrombophlebitis. It includes
phlebectomy, necrectomy, drainage and suturing of the wound (in parallel with antibiotic
therapy). Endovascular technologies (thrombectomy, selective thrombolysis, installation of a coffee
filter) are used in situations with phlebothrombosis.
5) Possible complications of this disease?
thrombophlebitis; chronic venous insufficiency; thrombosis; pulmonary embolism (PE); abscess
(with infectious phlebitis).
Task 17
A patient with duodenal ulcer and increased bleeding was admitted to the surgical department. The
BCC deficit is 35%. In order to restore blood loss, the patient is shown an emergency blood
transfusion.
1) What volume of laboratory tests should be performed on a patient without whom blood
transfusion is impossible?
1. Two-stage test in test tubes with antiglobulin
2. Compatibility test on a plane at room temperature
3. Indirect Coombs' test
4. Compatibility test using 10% gelatin
5. Compatibility test using 33% polyglucin
2) How are these tests performed? Execution technique.
.1. Two-stage test in test tubes with antiglobulin
The first stage. 2 volumes (200 μl) of recipient serum and 1 volume (100 μl) of 2% suspension of
triple-washed donor erythrocytes suspended in saline or LISS (low ionic strength solution) are
added to the labeled tube. The contents of the tubes were stirred and centrifuged at 2500 rpm (about
600 g) for 30 s. The presence of hemolysis in the supernatant is then assessed, after which the
erythrocyte sediment is resuspended by lightly tapping the bottom of the tube with a fingertip, and
the presence of erythrocyte agglutination is determined. In the absence of severe hemolysis and / or
agglutination, proceed to the second stage of the test using antiglobulin serum.
The second stage. The tube is placed in a thermostat at 37 ° C for 30 minutes, after which the
presence of hemolysis and / or agglutination of erythrocytes is again assessed. The erythrocytes are
then washed three times with saline, 2 volumes (200 μl) of antiglobulin serum are added for the
Coombs test and mixed. The tubes are centrifuged for 30 s, the erythrocyte pellet is resuspended
and agglutination is assessed.
The results are recorded with the naked eye or through a magnifying glass. Severe hemolysis and /
or agglutination of erythrocytes indicates the presence in the recipient's serum of group hemolysins
and / or agglutinins directed against the erythrocytes of the donor, and indicates incompatibility of
the blood of the recipient and the donor. The absence of hemolysis and / or agglutination of
erythrocytes indicates the compatibility of the blood of the recipient and the donor.
.2. Compatibility test on a plane at room temperature
Apply 2-3 drops of recipient serum to the plate and add a small amount of erythrocytes in such a
way that the ratio of erythrocytes and serum is 1:10 (for convenience, it is recommended to first
release a few drops of erythrocytes from the container to the edge of the plate, then transfer a small
glass rod a drop of erythrocytes in serum). Next, the erythrocytes are mixed with serum, the plate is
shaken slightly for 5 minutes, watching the reaction. After this time, 1-2 drops of saline can be
added to the reaction mixture to remove possible nonspecific erythrocyte aggregation.
Accounting for results. The presence of erythrocyte agglutination means that the donor's blood is
incompatible with the recipient's blood and should not be transfused. If after 5 minutes there is no
agglutination of erythrocytes, it means that the donor's blood is compatible with the recipient's
blood on group agglutinogens.
3. Indirect Coombs' test
One drop (0.02 ml) of the precipitate of the donor's erythrocytes washed three times is added to the
test tube, for which a small drop of erythrocytes is squeezed out of the pipette and touches the
bottom of the tube, and 4 drops (0.2 ml) of recipient serum are added. The contents of the tubes are
stirred by shaking, after which they are placed for 45 minutes in a thermostat at a temperature of +
37 ° C. After this time, the erythrocytes are washed again three times and prepare a 5% suspension
in saline. Next, 1 drop (0.05 ml) of erythrocyte suspension on a porcelain plate, add 1 drop (0.05
ml) of antiglobulin serum and mix with a glass rod. The plate is periodically shaken for 5 minutes.
The results are recorded with the naked eye or through a magnifying glass. Erythrocyte
agglutination indicates that the blood of the recipient and the donor are incompatible, the lack of
agglutination is an indicator of the compatibility of the blood of the donor and the recipient.
4. Compatibility test using 10% gelatin
1 small drop (0.02 - 0.03) ml of erythrocytes of the donor is introduced into the test tube, for which
a small drop of erythrocytes is squeezed out of the pipette and it touches the bottom of the test tube,
2 drops (0.1 ml) of gelatin and 2 drops are added. ml) serum of the recipient. The contents of the
tubes are stirred by shaking, after which they are placed in a water bath for 15 minutes or a
thermostat for 30 minutes at a temperature of +46 - 48 ° C. After this time, add 5 to 8 ml of saline to
the tubes and mix the contents by inverting the tubes 1-2 times.
The result is taken into account by looking at the tubes for light with the naked eye or through a
magnifying glass. Erythrocyte agglutination indicates that the blood of the recipient and the donor
are incompatible, the lack of agglutination is an indicator of the compatibility of the blood of the
donor and the recipient.
5. Compatibility test using 33% polyglucin
2 drops (0.1 ml) of recipient serum 1 drop (0.05) ml of donor erythrocytes are added to the test tube
and 1 drop (0.1 ml) of 33% polyglucin is added. The tube is tilted to a horizontal position, shaking
slightly, then slowly rotated so that its contents spread along the walls in a thin layer. This
spreading of the contents of the test tube on the walls makes the reaction more pronounced. Contact
of erythrocytes with serum of the patient at rotation of a test tube should be continued not less than
3 min. After 3-5 minutes, add 2-3 ml of saline to the test tube and mix the contents by inverting the
test tube 2-3 times without shaking.
The result is taken into account by looking at the tubes for light with the naked eye or through a
magnifying glass. Erythrocyte agglutination indicates that the blood of the recipient and the donor
are incompatible, the lack of agglutination is an indicator of the compatibility of the blood of the
donor and the recipient.
3) Possible errors.
1. Low quality reagents
2. Technical errors:
• Use of contaminated equipment (pollution
standard sera and other groups).
• Poor SALT and tlennya will prevent is to detect ahlyutynats and S or its
in and dsutn and st .
• Too strong tsentryfuhuvannnya (false positive result), the lack is centrifugation (false negative
result).
• P and dvyschena temperature was over 25 ̊S and zko UPOV and lnyu is ahlyutynats and th .
At low and also the temperature and (less than 15 ̊S) may nespetsyf and hours on ahlyutynats and I
• Improper marking and handling of the reagent and c
• Incorrect well of her reactions AI
• Early VH and the NCA results and in
• GW and honor ahlyutynats and I
• Nedodavannya f and on and oloh and chnoho solution
• Psevdoahlyutynats Exposure
Task 18
In order to quickly restore blood loss, the patient was transfused with 1000 ml of one-group rhesus-
compatible donor blood preserved with sodium citrate. By the end of the blood transfusion, the
patient developed agitation, pale skin, tachycardia, convulsions.
1) What complication developed in the patient?
Citrate intoxication
2) Prevention of complications.
Prevention is to limit the rate of transfusion of citrate-containing media. The infusion should be
performed at a frequency of about 50 ml / minute. People prone to developing hypocalcemia are
advised to transfuse washed erythrocytes that do not contain citric acid. If it is necessary to use
citrate components for each liter of transfused blood, the patient should receive 10 ml of 10% Ca-
gluconate. If the procedure must be performed at high speed (critical conditions, acute blood loss),
the drug is administered every 0.5 liters of transfusion medium.
3) Treatment of complications.
H emedlennoe prekraschenye transfusion. If the expressed disturbances of hemodynamics and work
of the muscular device are absent, correction by means of drugs is not shown. At a bright clinical
picture to the patient intravenously enter chloride or gluconate of calcium in quantity of 10-20 ml of
10% of solution.
Citrate intoxication, which occurs in an extremely severe form, requires resuscitation. At sharp
bradycardia enter atropine, cardiotonics. Generalized seizures are relieved with relanium,
magnesium sulfate, barbiturates. If a person is on artificial lung ventilation , muscle relaxants can be
used in combination with hypnotics for this purpose. The introduction of calcium supplements
under the control of the electrolyte composition of the blood is shown.
Task 19
The patient underwent a bioassay for compatibility before blood transfusion. According to a
previous study, it is compatible with the ABO system and Rh factor. 45 ml of donor blood was
injected intravenously in 15 ml with an interval of 3 min. During the introduction of the last portion,
the patient developed nausea, fever, low back pain, chest pain, dizziness, palpitations and
respiration, decreased blood pressure.
1) What happened?
Blood transfusion shock
2) Is the biological test performed correctly?
No, wrong
3) Your actions.
1. Stop blood transfusion. However, the needle should not be removed from the vein, as the
development of shock will cause insurmountable difficulties in obtaining new venous access. It is
better to connect the system with a crystalloid solution.
2 Begin transfusion of hemodynamic blood substitutes.
3. Introduce the following drugs
• narcotic analgesics;
• antihistamines
• corticosteroids (50 - 150 mg of prednisolone or 250 mg of hydrocortisone);
• cardiac glycosides, cordiamine, caffeine;
• euphyllin;
• sodium bicarbonate or lactate (to remove hemolysis products);
• diuretics (lasix, mannitol).
4. Conduct oxygen therapy.
Task 20
Patient K. 27 years old, delivered with a stab wound to the abdomen 4 hours after injury. The
patient's condition is extremely serious. The pulse is filiform, 120 for 1 min. Blood pressure - 70
and 40 mm Hg. Art. An emergency laparotomy was performed. There is a lot of blood and clots in
the abdomen. After aspiration of blood, the source of bleeding was identified: the vessels of the
mesentery of the small intestine. Hemostasis was performed. No lesions of the cavity organs were
detected.
1) What to do with the blood that got into the abdominal cavity?
P infusion of blood poured into the abdominal cavity.
2) Method of autoreinfusion.
Method of blood collection by aspiration . Blood collected in stabilizer vials is filtered through 8
layers of gauze. To preserve the blood, use either a solution of TsOLIPK № 7b in a ratio of 1: 4
with blood, or a solution of heparin - 10 mg in 50 ml of isotonic sodium chloride solution per vial
with a capacity of 500 ml. Blood is infused intravenously through a transfusion system using
standard filters.
3) Indications and contraindications to autoreinfusion.
Shows. P ri bleeding obuslovlennыh INJURIOUS organs abdominal cavity (gap spleen, liver,
vessels mesentery) organs thoracic cells (vnutryplevralnom bleeding, gap intrathoracic vessels,
lung), impaired vnematochnoy beremennostyu at travmatychnыh operations on the bones of the
pelvis, bedrennoy bones, spine, soprovozhdayuschyhsya Bolshoi intraoperative blood loss.
Contraindications. 1) damage to the hollow organs of the chest (large bronchi, esophagus) and the
hollow organs of the abdominal cavity (stomach, intestines, gallbladder, extrahepatic bile ducts,
bladder); 2) malignant neoplasms; 3) hemolysis of spilled blood and the presence of foreign
impurities in it. It is not recommended to transfuse blood that has been in the abdomen for more
than 12 hours (possibility of defibrillation and infection)
4) Possible complications
Complications of a mechanical nature: acute dilatation of the heart , recurrent
embolism and I, thromboembolism and thrombosis .
Task 21
Patient N. was 31 years old, blood group 0 (I) was in the district hospital due to aborted pregnancy,
posthemorrhagic anemia. Group B (III) blood transfusion was started by mistake. After the
introduction of 800 ml of blood there was pain in the lumbar region, fever. The transfusion was
stopped. After 15 minutes, the patient's condition suddenly deteriorated: lethargy, sharp pallor of
the skin, acrocyanosis, profuse sweating, fever pronounced. Pulse - 96 per minute, weak
filling. Blood pressure - 75/40 mm Hg. Art .
1) What complication developed in the patient?
Blood transfusion shock
2) What treatment measures should be taken?
-crystaloids and colloids (isotonic sodium chloride solution, polyglucin, reopolyglucin, refortan,
stabizol) in an amount sufficient to restore and stabilize systolic blood pressure at up to 100 mm Hg.
- polyionic solutions
- (dopamine, norepinephrine) in / in drip;
-classical anti-shock triad: prednisolone (90-120 mg, possibly up to 5 mg / kg), euphylline (10 ml of
2.4% solution) and lasix (100 mg);
-antihistamine drugs (diphenhydramine, tavegil) and narcotic analgesics (promedol);
- heparin and its low molecular weight derivatives (fraxiparin, klexan, enoxyparin in a dose)
It is very important to inject 5,000 IU of heparin intravenously as early as possible, and in the next
24 hours to slowly inject 1000-1500 IU per hour. Contraindications to the use of heparin and its
derivatives are signs of hypocoagulation and extensive fibrinolysis.
-100-200 mg lasix
Task 22
The victim M., 38 years old, who was burnt by a fire on the street about 1 hour ago, was taken to
the hospital's admission department. Circular burns of the right upper extremity, right lower
extremity and perineum "marble", pale gray, covered with soot and remnants of the epidermis are
determined. The skin on the intact areas of pale skin. t - 36.0 ° C; CDR - 16 / min; AT-100/60 mm
Hg; Pulse - 96 / min. Laboratory: Hb - 180 g / l; Er. - 5.7x1012 / l Ht - 56%.
1. What condition can be diagnosed in a patient and what is the main criterion for its
determination?
Moderate burn shock Criteria: tachycardia, hypotension, hemoconcentration ( Hb 180g / l)
2. Determine the approximate area of the lesion? Methods of determination.
The area of the lesion = 28% (upper limb 9%, lower limb 18% perineum 1%). Methods of
determination: rule of nines (head and neck - 9%, upper limb - 9%, lower limb - 18%, anterior
torso - 18%, posterior torso - 18%, perineum and genitals - 1%.) ; The rule of the palm,
the method of GD Vilyavina, tables BM Postnikov, method VA Valley (graphic)
3. Assign a set of urgent measures?
- Elimination of influence or neutralization of the damaging factor.
- Anesthesia. nalbuphine 1% or 2% 1 ml; norfin 0.2% 1 ml; herd 0.2% 1 ml every 3-4
hours. ketonal (100 mg), xefokam (8 mg), ketans (30 mg)
- Ensuring patency of the upper respiratory tract.
- Rehydration (oral or intravenous infusion therapy). Modified Parkland formula : V infusion (ml)
= 2 (ml) × patient weight (kg) ×% burn surface (in the first 6-8 hours)
-Detection of combined injury (combined lesion)
-In the presence of a combined injury: immobilization, cessation of bleeding.
-Monitoring of vital functions (blood pressure, heart rate, respiratory rate and depth, level of
consciousness).
- Transportation of the victim to the nearest medical institution.
4. Define the criteria for monitoring the patient's condition and the end of the OS stage?
blood pressure, heart rate, respiratory rate and depth, level of consciousness improve to normal
Task 23
Patient A., 55, who was injured at home 5 days ago, was taken to the cremation ward from the
district hospital. Diagnosis: Flame burn I-IIAB degree of the face, hands and forearms, lower
extremities 40 (16)% p.t. Burn disease, severe. Antishock therapy was performed in a timely and
adequate manner. The patient complains of pain in the areas of burns, general weakness. t - 37.8 °
C; CDR - 18 / min; AT-110/70 mm Hg; Pulse - 84 / min. Laboratory: Hb - 112 g / l; Er. -
3.25x1012 / l; L - 9.8x109 / l; total protein - 48 g / l. Topically: burns are covered with a dark brown
dry scab, there are minor serous-hemorrhagic discharge.
1. What stage of burn disease can be diagnosed in a patient?
O peak disease, stage of acute burn toxemia
2. What tactics of surgical treatment are optimal in this period?
Necrectomy, gradual free autodermoplasty; reticular grafts
3. Detoxification therapy. What drugs should be used to correct the level of hypoproteinemia?
Anabolic steroids are used to stimulate protein synthesis in tissues: nerobol, retabolil, pentoxil
- saline and salt-free solutions, colloidal plasma substitutes
- forced diuresis with the use of seluretics (Lasix from 4-6 to 10 ml per day).
-immune plasma or immunoglobulin of burn convalescents, which contain antitoxic "anti-burn" and
antibacterial antibodies. The therapeutic dose is 4-7 ml / kg body weight per day of plasma burns -
convalescents daily or every other day for 5-7 days
- Carry out vitamin therapy: B1, B6, B12, C, E.
-To improve liver function use hepatoprotectors: essential, syrup, legalon.
- Pour leukocyte mass in 2-3 doses and intramuscularly administered thymalin or splenin at a dose
of 20 mg for 7 days
4. What measures should be taken to prevent infectious complications of burns?
separate ward for 1 patient
- Installation of a microclimatic complex in a separate ward, which supplies sterile purified air of a
given temperature from below through a hydrophobic mesh bed for the patient's body, provides
adequate insulation and optimizes the treatment process for circular burns
-antibacterial drugs sensitive to flora (combination of several groups)
-prevention of tetanus
Task 24
Boy V., 2 years old, got a burn at home 30 minutes ago when he accidentally overturned a cup of
hot tea. The parents immediately took the child to the burn unit on their own. On examination: in
the face, neck, front and back of the torso, right shoulder and forearm, there are multiple blisters
filled with transparent, light yellow contents, the removal of which exposes pink sharply painful
burns. The doctor determined the area of the lesion to be 12% p.t.
1. Set the degree of damage. Describe the extent of the lesion.
The second stage of skin damage, because we see bubbles filled with fluid and when they are
exposed, wounds are formed.
2. Identify the basic principles of first aid.
. First aid .
2.1: Immediately cool the burn with cold water for 5-10 minutes
2.2: After washing, if possible, apply panthenol to the burn, then apply a damp gauze. The main
thing is not to pierce the blisters yourself! If the blisters burst on their own, apply sterile gauze. If
possible, give painkillers analgin, ketones, nurofen.
3. Stages and phases of the wound burn process.
4. Describe the principles of local treatment.

Local treatment: Primary toilet of a burn wound. Foreign bodies are removed from the burnt
surface, exfoliated epidermis is removed, large blisters are dissected, contaminated areas of the burn
wound are fused with a solution of antiseptics, chlorhexidine, hydrogen peroxide, the burn wound is
dried with sterile wipes and covered with a bandage. antiseptics .In the future, you can use
ointments (chloramphenicol) .During bandaging, rehabilitate the burn wound, remove necrotic
tissue with scissors and tweezers .TEN IMPOSE A BAND IMPOSED ANTIBIOTICS.
Surgical treatment.
From surgical methods use: Necrectomy, autodermoplasty, in case of widespread burns use skin-
fascial grafts.
Task 25
A 22-year-old patient had pain in her right breast on day 17 after delivery, and her body temperature
rose to 38.5 ° C. Objectively, the skin in the upper outer quadrant of the right breast is hyperemic,
hot to the touch, swollen, on palpation the patient notes an increase in pain. Inguinal lymph nodes
are enlarged, painful.
1. What is the probable diagnosis of the patient?
Lactational mastitis of the right breast.
2. What laboratory and instrumental methods of examination will allow to correctly
determine the diagnosis?
Breast ultrasound, diagnostic drainage by needle aspiration, cytological, bacteriological
examination of punctate / milk, ZAK.
3. With which diseases of the breast in the first place it is necessary to make a differential
diagnosis?
Galactocele, fibrocystic mastopathy, primary invasive breast cancer.
4. What are the treatment tactics?
Effective milk removal and symptomatic therapy:
ibuprofen: 200-400 mg orally every 4-6 hours as needed, maximum dose - 2400 mg / day
increase the frequency of breastfeeding, fluid intake, warm and / or cold compresses, massage
- Empirical antibiotic therapy:
flucloxacillin: 250-500 mg orally 4 times a day or
dicloxacillin: 250-500 mg orally 4 times a day or
cloxacillin: 250-500 mg orally 4 times a day
Task 26
A 45-year-old woman went to the doctor with complaints of pain and tightness in the right breast,
fever up to 37.5 ° C. From the anamnesis it is known that the pain in the right breast appeared a
week ago (after hypothermia). The patient noticed the temperature and seals in the breast 2 days
ago. Mammographic examination 6 months ago - without additional tumors. Objectively: in the
right breast in the lower-inner quadrant moderately swollen area of tissue, painful, hot to the touch
is palpated. The nipple-areolar complex is not changed. From the nipple there is a greenish
discharge. Inguinal l / nodes are moderately painful, enlarged .
1. Establish a diagnosis.
Non-lactational mastitis of the right breast.
2. What are the additional diagnostic methods?
Mammography, diagnostic drainage by needle aspiration, cytological, bacteriological examination
of punctate / secretions, ZAK.
3. Prescribe treatment tactics?
- Empirical antibiotic therapy:
flucloxacillin: 250-500 mg orally 4 times a day or
dicloxacillin: 250-500 mg orally 4 times a day or
cloxacillin: 250-500 mg orally 4 times a day
Secondary options
cephalexin: 500 mg orally 4 times a day or
clindamycin: 300–450 mg orally 4 times a day
- Symptomatic therapy:
paracetamol: 500-1000 mg orally every 4-6 hours as needed, maximum dose 4000mg / day or
ibuprofen: 200-400 mg orally every 4-6 hours as needed, maximum dose - 2400 mg / day
4. With what diseases of a mammary gland first of all it is necessary to carry out differential
diagnosis?
Fibrocystic mastopathy, primary invasive breast cancer, intraductal papilloma, ectasia, abscess.
Task 27
A 24-year-old girl complained to a surgeon about a tumor in her left breast. Discovered on their
own 3 days ago after menstruation during self-examination. Palpation reveals a round, mobile
tumor measuring approximately 2 cm. The skin over the tumor is not changed, the axillary l / nodes
are not enlarged, painless.
1. Make a diagnosis.
Fibroadenoma of the left breast.
Ultrasound of the mammary glands, fine-needle aspiration biopsy, sectoral resection of the breast,
ZAK.
Sectoral resection of the breast.
4. With which diseases of the breast in the first place it is necessary to conduct a differential
diagnosis?
Plasmacytic mastitis, breast cancer.
TASK 28
A 42-year-old woman, who has been periodically seen by a mammologist for 10 years, complains
of pain, a feeling of fullness in the mammary glands before menstruation, the periodic appearance
of white discharge from the nipple. After menstruation found a seal in the right breast. Objectively:
the skin of the right breast is not changed, palpable mobile, without clear contours, moderately
painful, dense area of tissue up to 4 cm in diameter, in the upper outer quadrant. Inguinal l / nodes
are not changed.
1. Establish a possible diagnosis.
FKM, or nodular form ( cancer of the breast, nodular form);
2. What are the appropriate additional diagnostic methods?
Mammography, ultrasound of the breast, fine-needle puncture biopsy (followed by cytological
examination) under the control of ultrasound, trepan biopsy (followed by histological examination -
histological classification, degree of differentiation, estrogen and progesterone receptors),
cytological examination of the discharge from the nipple, U
If cancer is confirmed - to detect distant metastases (radiography of OGK, ultrasound of the
abdominal cavity, pelvis; or CT, MRI of these areas; scintigraphy of skeletal bones);
Surgical treatment - the amount depends on the final diagnosis. If the nodular form of PCM is a
simple mastectomy according to Madden (at a size > 3 cm - sectoral resection is contraindicated), if
the nodular form of breast cancer - surgery by Patty or Halsted with subsequent plastic
reconstruction of the gland. In malignant course + adjuvant chemotherapy, hormone therapy and
radiation therapy.
diagnosis?
Differential diagnosis - fibroadenoma, cyst, tuberculosis of the breast, nodular form of breast
cancer!
Task 29
The 56-year-old patient first consulted a mammologist. Complains of periodic dark discharge from
the nipple of the left breast. From the anamnesis: menopause, two children, breastfeeding in the
past. On examination: the nipple-areolar complex is not changed, the nipple is normal in shape
without retraction, when pressed, a black-brown liquid is released from it. Lymph nodes are not
changed.
Cancer of the breast;
histological classification, degree of differentiation, estrogen and progesterone receptors), in the
presence of secretions - ductography, cytology , Ultrasound of regional lymph nodes,
If cancer is confirmed - to detect distant metastases (radiography of OGK, ultrasound of the
abdominal cavity, pelvis; or CT, MRI of these areas; scintigraphy of skeletal bones);
Surgical treatment - surgery by Patty or Halsted with subsequent plastic reconstruction of the gland
+ adjuvant chemotherapy, hormone therapy and radiation therapy.
diagnosis?
Differential diagnosis - mastitis, fibroadenoma, FCM, cyst, breast tuberculosis.
Task 30
The patient, 65 years old, went to the doctor with complaints of pain and swelling of the left
breast. From the anamnesis: mammography examination 3 years ago - without pathology, the
symptoms of the disease appeared gradually during the last 2 months. Examination in the / outer
quadrant of the left breast, as well as in the nipple-areolar area reveals swollen, moderately
hyperemic skin, palpation - edema, tissue is moderately compacted, not painful, the tumor is not
defined, there is no discharge from the nipple. Inguinal l / nodes on the left are enlarged, sedentary.
Cancer of the breast, swelling infiltrative-form
presence of secretions - ductography, cytology , Ultrasound of regional lymph nodes,
To detect distant metastases (radiography of OGK, ultrasound of the abdominal cavity, pelvis; or
CT, MRI of these areas; scintigraphy of skeletal bones);
Preoperative non-adjuvant chemotherapy radiation therapy surgical treatment (extended
inguinal-thoracic radical mastectomy) adjuvant chemotherapy and hormone therapy.
diagnosis?
Differential diagnosis - mastitis, erysipelas.
Task 31
A 62-year-old patient went to a neurologist with complaints of back pain. He denies injuries. The
radiograph of the thoracic spine revealed a pathological fracture of 9-10 thoracic vertebrae. During
the examination, the surgeon found in the lower-inner quadrant of the left breast a tumor up to 2.5
cm, immobile, a positive symptom of the "site", a characteristic "umbilical cord". Inguinal lymph
nodes on the left are enlarged, immobile, painless on palpation.
Cancer of the breast, nodular form;
presence of secretions - ductography, cytology , Ultrasound of regional lymph nodes.
To detect distant metastases (radiography of OGK, ultrasound of the abdominal cavity, pelvis; or
CT, MRI of these areas; scintigraphy of skeletal bones);
3. What is the stage of the disease?
Stage 4;
Palliative treatment. The main value is chemotherapy and hormone therapy. At threat of bleeding,
disintegration of a tumor - surgical treatment (mastectomy). Operations on other organs on vital
signs. Radiation therapy.
Task 32 The
pediatric surgeon was called to the newborn in connection with severe vomiting with bile, which
began 10 hours after birth. From the anamnesis: the child was born at 38 weeks of pregnancy
naturally. Polyhydramnios was detected by intrauterine ultrasound during the third trimester.
Meconium discharge was not observed. On examination: the abdomen is enlarged due to the
epigastrium, stretched, soft. Review radiograph of the abdominal cavity is presented. Establish the
most likely diagnosis in the child.
Diagnosis: Pylorospasm (because vomiting from bile), but we do not see X-ray examination may
be pylorostenosis (because surgical treatment of pylorostenosis)
Task 33
A 12-year-old boy was taken to a pediatric surgeon with complaints of fever up to 39 ℃ , general
weakness, severe pain in the lower extremity. From the anamnesis it is known that the pain
appeared after the injury and intensified after 5 days. He is under dispensary supervision for chronic
tonsillitis, has untreated carious teeth. On examination: the left lower extremity occupies a forced
position, active and passive movements are limited and sharply painful, the upper and middle third
of the left leg is enlarged, the skin is swollen, hyperemic, hot to the touch. Percussion of the left
tibia is sharply painful. Blood test: L -28 x 109 / l, ESR-34mm / g, p-21%, CRP-98mg / l. The
results of X-ray examination of the affected limb are given. Establish the most probable diagnosis in
the child.
Diagnosis: Acute (hematogenous?) Osteomyelitis.
Task 34.
A 14-year-old boy was taken by ambulance with complaints of a
sharp, "dagger pain" in his abdomen. The pain began acutely after stress at school and
the consumption of spicy foods and coffee. There is no history of ulcers. Facial features
are pointed. The skin is pale, covered with cold sweat. Tachycardia up to 120 / min., Pulse of small
filling, blood pressure - 90/60 mm Hg. Occupies a forced position and every movement causes
excruciating pain. On palpation, the abdomen is "board-shaped", does not participate in respiration,
the symptom of Shchotkin-Blumberg is positive. The result of the review radiography of the
abdominal cavity is given.
Set diagnosis in this patient:
Answer: Perforated ulcer
Task 35.
The boy's parents V., 7 weeks old, first degree of
prematurity (born at 36 weeks of pregnancy), birth weight 2445 g , went to the hospital .
The mother complains that the child is lethargic, irritated, vomits whole milk for almost two weeks
after each feeding. bile impurities. Weight loss is 10%. Body temperature 36.6 0C. The condition is
severe, malnutrition of the second degree. The skin is pale, clean. Heart sounds are weakened, heart
rate - 130 per minute. Breathing 31 per minute vesicular, symmetrical. The abdomen is soft, the
child responds to palpation calmly, you can see the peristalsis of the stomach, on the right near the
edge of the right rectus abdominis above the navel is palpated oval dense formation, 2-3 cm
long. Symptoms of peritoneal irritation are negative. The liver is not enlarged. Urine is intensely
yellow. Stool 2 times a day, mushy, yellow, without pathological impurities. Hemoglobin - 100 g /
l; Er. - 3,4х 109 / l; k.p. - 0.6; Leukocytes - 12.2x109 / l; e - 1%; n - 8%; c - 66%; l - 22%; m -
3%; Platelets - 230x109 / l; ESR - 16 mm / year; pH 7.49; chloride - 90 mmol / l; bicarbonate -
32 mmol / l; potassium - 3.0 mmol / liter. 1. What is the clinical diagnosis?
Congenital pylorostenosis
2. What is the nature and etiology of this disease?
Pylorostenosis is caused by a complex influence of hereditary factors and environmental factors,
which can be conditionally grouped as follows:
I. Endogenous factors:
 changes in genetic structures (gene mutations and chromosomal aberrations);
 endocrine diseases;
 "maturation" of germ cells;
 age of parents.
ІІ. Exogenous factors:
1. Physical factors:
 radiation;
 mechanical.
2. Chemical factors:
 medicines;
 chemicals used in household and industry;
 hypoxia;
 poor nutrition.
3. Biological factors:
 viruses;
 mycoplasmas;
 protozoan infections;
 isoimmunization.
III. Multifactorial.
Isolated forms of congenital pylorostenosis are often of multifactorial origin .
3. What tests should be ordered to confirm the diagnosis?
- on palpation of the abdomen, the possibility of detecting a dense mobile pylorus above the navel
and to the right of it
- at ultrasound of pyloric department of a stomach ( characterized by thickening of a muscular
layer, lengthening of the pyloric channel and disturbance of evacuation of food masses from a
stomach. At cross scanning pyloric department has the form of the round formation consisting of a
hypoechoic crown and the hyperechogenic center - "finger" eye ". In the longitudinal scan of the
pyloric department is visualized as a cylindrical formation with thickened walls up to 4 millimeters
or more )
- with FEGDS ( there is a point hole in the gatekeeper, convergence of the folds of the mucous
membrane of the antrum of the stomach towards the narrowed gatekeeper, with air insufflation, the
gatekeeper does not open, an attempt to endoscope in the duodenum is impossible. When atropine
test, the gatekeeper remains closed ) .
-for radiography use a 5% solution of barium in 25 - 30 ml of breast milk or a mixture that is
injected into the stomach through a tube. X-rays are taken before contrast, 10 to 20 minutes after
contrast, and 3 to 6 to 24 hours.
Radiographic signs are direct and indirect. Direct characterize the state of the lumen and walls of
the pyloric canal:
 With the symptom of "antral beak" (when the solution is injected into the stomach, it approaches
the pyloric region, the pyloric canal is opened and the mass fills its initial part, then the lumen of the
canal is closed due to spasm or hypertrophy of the muscles of the walls and the radiograph shows a
rounded contour of the antrum ending in a wedge-shaped, beak-shaped protrusion.
 Symptom of "flagellar tendril", indicating narrowing and elongation of the pyloric canal.
 The symptom of "shoulders", or "brace" - is a kind of intussusception, when the hypertrophied
walls of the pyloric canal enter the antrum of the stomach, or, conversely, the wall of the antrum is
approaching the hypertrophied rigid portal.
 Increased expression of the folds of the gastric mucosa.
Indirect signs of pylorostenosis characterize the condition of the stomach and intestines (the
presence of liquid in the stomach on an empty stomach), a small amount or complete absence of gas
in the intestine, delayed evacuation of barium from the stomach, low filling, or no contrast of the
duodenum (3 - 24 h after input).
4. What are the tactics of treatment?
Surgical treatment
Preoperative preparation: carried out in the intensive care unit by an anesthesiologist to correct
water and electrolyte disorders and acid-base status for 24-48 hours, depending on the patient's
condition.
Surgical treatment: pyloromyotomy according to Fred-Ramstedt
P islyaoperatsiyne treatment :
- infusion therapy to correct impaired water-electrolyte, protein metabolism and acid-base status,
-enteral nutrition in uncomplicated cases 6 hours after surgery, 10 ml of breast milk or adapted
mixture every 2 hours, gradually increasing its amount; in complicated cases (with perforation of
the mucous membrane) - nasogastric tube and starvation for 24 hours, then - enteral nutrition, also
starting with 10 ml of breast milk or mixture every 2 hours .
Dispensary observation : performed by a pediatrician and a surgeon at the place of residence for 6
months
5. Interpret the results of the blood test
Hemoglobin - reduced (norm 103-141 g / l); er. -norm; k.p. - reduced (rate 0.85 -
1.15%); leukocytes - norm; e - norm; n - increased (norm 0.5 - 5%); c - significantly increased
(norm 16 - 45%); l - reduced (norm 45 - 70%); m - norm; platelets - normal; ESR - elevated (norm
4-10 mm / h); pH 7.49 (indicates alkalosis, norm 7.35 - 7.45); chloride - 90 mmol / l (reduced, the
norm is 98 - 107 mmol / l); bicarbonate - 32 mmol / l (increased, norm11.9-22.9 mmol /
l); potassium - 3.0 mmol / l (reduced, the rate of 3.5 - 5.1 mmol / l).
Task 36
The boy M., 2 days of life, vomiting with bile impurities from the beginning of enteral nutrition
(breastfeeding).
From the anamnesis of life it is known: born from the second pregnancy, 38 weeks, childbirth
physiological, Apgar scale 8 points for 3 minutes, birth weight 3115 g, height 48 cm In the mother
prenatal ultrasound from 20 weeks revealed polyhydramnios.
The general condition of the child is severe, the skin is pale, clean. Heart sounds are weakened,
heart rate - 132 per minute. Breathing 34 per minute, vesicular, symmetrical. The abdomen is soft,
diffusely swollen, the child does not respond to palpation. Symptoms of peritoneal irritation are
negative. The liver is not enlarged. Yellow urine. On the second day of life, meconium, gray in
color, only 2-3 ml.
On the review radiograph of the OCP in the vertical position revealed three levels of fluid and the
absence of gas in the distal intestine. On ultrasound OChP, retroperitoneal space, heart, brain
pathology is not revealed.
Examination of concomitant anomalies did not reveal.
1. What is the most likely diagnosis?
 Congenital high partial duodenal intestinal obstruction (the barrier is located below the
large papilla of the duodenum).
2. What is the etiology of this disease?
 In newborns, the etiological factors of congenital intestinal obstruction are defects in the
development of the intestinal tube in embryogenesis. Factors of duodenal obstruction can
be: membranous atresia, membranous stenosis. If the lumen of the intestinal tube is closed
at a great distance, atresia is formed in the form of a fibrous cord. Sometimes it occurs due to
underdevelopment of the corresponding branch of the mesenteric vessels. More often these
defects arise in sites of difficult embryonic processes - a large papilla of a duodenum, in a
place of transition of a duodenum to a small bowel.
 Variants of duodenal obstruction in pancreatic malformations: annular pancreas, claw-like
head of the pancreas, an additional piece of software in the wall of the 12th intestine that
narrows the intestinal lumen.
3. What is the classification of this disease?
Types of intestinal atresia:
 Intestinal stenosis.
 Membrane form of atresia (type I according to the EUPSA classification), in which
the diameter of the intestine remains normal, but the intestinal lumen is blocked by a
membrane formed of the mucous and submucosal layers of the intestine. The
membrane can be continuous - in this case, acute intestinal obstruction develops, or
have a perforation, which can cause the development of chronic intestinal
obstruction.
 The two sections of the intestinal tube end blindly and are connected by a fibrous
cord (type II). There is no mesentery defect, the total length of the intestine usually
does not change.
 Complete rupture of the intestinal tube in a certain area (type III a). There is a
defect of the mesentery, shortening of the intestine of varying degrees.
 Multiple intestinal atresia (type IV).
Classification of intestinal obstruction:

Originally:
a) congenital b) acquired.
According to the state of patency of intestinal contents:
a) full b) partial.
According to the clinical course:
a) acute b) chronic.
By causal factor:
a) mechanical: 13 - strangulation (blood supply disorders, venostasis): pinching, torsion,
nodules; -obturation (tumor, foreign body, worm tangle, coprostasis, external
compression); -mixed (intussusception).
b) dynamic: - spastic (neurogenic, hysterical, poisoning by zinc oxide, lead, arsenic,
nicotine, fungi); - paralytic (peritonitis, spinal cord injury, poisoning, etc.);
According to the level of obstruction, there are high GKN (small intestine) and low GKN
(small and large intestine)
4. With what diseases is the differential diagnosis made?
 Pylorospasm.
 Congenital pylorostenosis.
 Congenital hernia of the diaphragm.
 Childbirth brain injury.

 Preoperative preparation, which lasts up to 12-24 hours in the absence of congenital
torsion of the midgut. Children are in an incubator at a temperature of 28-32 C, constantly
receive oxygen, infusion therapy (10% glucose solution, protein drugs) and anti-inflammatory
therapy are actively carried out.
 Surgical intervention for congenital intestinal obstruction in newborns: perform a right
paramedial incision up to 9-10 cm in length. With atresia and internal stenosis of the
duodenum perform a longitudinal duodenotomy 1 cm above the site of obstruction. The
membrane is circularly excised until the transition of the mucous membrane to the intestinal
wall. The wound of the 12th intestine is sutured with a double-row suture.
Task 37
The boy S., 2 days of life, vomiting with bile impurities from the beginning of enteral nutrition
(breastfeeding). Through a gastric tube aspirated 32 ml per day of green content.
From the anamnesis of life it is known: born from III pregnancy, physiological childbirth at 39
weeks, on the Apgar scale 8 points for 3 min., Birth weight 3201 g, height 47 cm. At prenatal
ultrasound of the mother from 20 weeks polyhydramnios, fetal symptom bubble. Down syndrome is
prenatally diagnosed.
The general condition of the child is severe, the skin is pale, clean. Heart sounds are weakened,
heart rate - 131 per minute. Breathing 36 per minute, vesicular, symmetrical. The abdomen is soft,
not bloated, the child responds to palpation calmly. Symptoms of peritoneal irritation are
negative. The liver is not enlarged. Yellow urine. Meconium did not leave. On the review
roentgenogram of OChP in a vertical position the symptom "double bubble" (expansion of a
stomach and a duodenum) is visualized, gas in distal parts of intestines is not visible. On ultrasound
OChP, retroperitoneal space, brain pathology is not revealed. On ultrasound of the heart -
ventriculoseptal defect, open ductus arteriosus, CH IIA.
Examination of concomitant anomalies did not reveal.
 Congenital high complete duodenal obstruction, atresia of the duodenum.
2. What is the etiology and classification of this disease?
 In newborns, the etiological factors of congenital intestinal obstruction are defects in the
development of the intestinal tube in embryogenesis. Factors of duodenal obstruction can
be: membranous atresia, membranous stenosis. If the lumen of the intestinal tube is closed
at a great distance, atresia is formed in the form of a fibrous cord. Sometimes it occurs due
to underdevelopment of the corresponding branch of the mesenteric vessels. More often
these defects arise in sites of difficult embryonic processes - a large papilla of a duodenum, in
a place of transition of a duodenum to a small bowel.
Types of intestinal atresia:
 Intestinal stenosis.
 Membrane form of atresia (type I according to the EUPSA classification), in which
the diameter of the intestine remains normal, but the intestinal lumen is blocked by a
membrane formed of the mucous and submucosal layers of the intestine. The
membrane can be continuous - in this case, acute intestinal obstruction develops, or
have a perforation, which can cause the development of chronic intestinal
obstruction.
 The two sections of the intestinal tube end blindly and are connected by a fibrous
cord (type II). There is no mesentery defect, the total length of the intestine usually
does not change.
 Complete rupture of the intestinal tube in a certain area (type III a). There is a
defect of the mesentery, shortening of the intestine of varying degrees.
 Multiple intestinal atresia (type IV).
Originally:
a) congenital b) acquired.
According to the state of patency of intestinal contents:
a) full b) partial.
According to the clinical course:
a) acute b) chronic.
By causal factor:
a) mechanical: 13 - strangulation (blood supply disorders, venostasis): pinching, torsion, nodules; -
obturation (tumor, foreign body, worm tangle, coprostasis, external compression); -mixed
(intussusception).
b) dynamic: - spastic (neurogenic, hysterical, poisoning by zinc oxide, lead, arsenic, nicotine,
fungi); - paralytic (peritonitis, spinal cord injury, poisoning, etc.);
According to the level of obstruction, there are high GKN (small intestine) and low GKN (small
and large intestine)
3. With what diseases it is necessary to carry out differential diagnosis?
 Pylorospasm.
 Congenital pylorostenosis.
 Congenital hernia of the diaphragm.
 Childbirth brain injury.
4. What additional special examinations should be performed to clarify the diagnosis?

 Preoperative preparation, which lasts up to 12-24 hours in the absence of
congenital torsion of the midgut. Children are in an incubator at a temperature of 28-32 C,
constantly receive oxygen, infusion therapy (10% glucose solution, protein drugs) and anti-
inflammatory therapy are actively carried out.
 Surgical intervention for congenital intestinal obstruction in newborns: perform a
right paramedial incision up to 9-10 cm in length. With atresia and internal stenosis of the
duodenum perform a longitudinal duodenotomy 1 cm above the site of obstruction. The
membrane is circularly excised until the transition of the mucous membrane to the
intestinal wall. The wound of the 12th intestine is sutured with a double-row suture.
Task 38
The boy's parents, R., from the age of Complaints of intermittent abdominal pain, delayed
defecation for up to 4-5 days, irritability of the child during the act of defecation. The mother makes
cleansing enemas every 3-4 days. The boy lags behind his peers in physical development.
From the anamnesis of life it is known: born from the first pregnancy, pregnancy without
complications, physiological childbirth at 38 weeks, on the Apgar scale 8 points for 3 minutes, birth
weight 3224 g, height 49 cm. The general condition of the child is satisfactory. The skin is pale,
clean. Subcutaneous fat is underdeveloped. Heart tones are rhythmic, pulse - 131 per
minute. Breathing 36 per minute, puerile, symmetrical. The abdomen is soft, slightly swollen, the
child responds to palpation calmly. Symptoms of peritoneal irritation are negative. The liver is not
enlarged. Yellow urine. Stools every 3-4 days after enema, stools of normal color, type I-II
according to the Bristol stool evaluation scale.
Examination per rectum revealed hematomas of the perianal area, the ampoule of the rectum
is filled with dense fecal masses. The tone of the sphincter is increased.
Hemoglobin - 94 g / l; Er. - 3.1x 109 / l; k.p. - 0.86; Leukocytes - 12.2x109 / l; e - 1%; n - 8%; c -
66%; l - 22%; m - 3%; Platelets - 230x109 / l; ESR - 16 mm / year; pH 7.39; chloride - 99 mmol /
l; bicarbonate - 28 mmol / l; potassium - 3.7 mmol / liter.
On the review roentgenogram of OChP in vertical position: the expanded intestinal loops
without horizontal levels of liquid.
On ultrasound OChP, retroperitoneal space, heart, brain pathology is not revealed.
Contrast irigography in direct and lateral projection: the distal part of the rectum is narrow
with a tunnel-like transit zone, which passes into the dilated intestine; recto-sigmoid index - 0.9.
Hirschsprung's disease
Classification of forms and stages of Hirschsprung's disease.
A. Anatomical forms.
1) Rectal form:
with lesions of the perineal rectum (Hirschsprung's disease with an ultrashort segment);
with lesions of the ampullar and suprampullar parts of the rectum (Hirschsprung's disease
with a short segment).
2) Rectosigmoid form:
with lesions of the lower third of the sigmoid colon;
with lesions of most or all of the sigmoid colon (Hirschsprung's disease with a long
segment).
3) Segmental form:
with one aganglionic segment in the rectosigmoid region or sigmoid colon;
with two aganglionic segments and a section of intact intestine between them.
4) Subtotal form:
with lesions of the left half of the colon;
with the spread of the pathological process on the right half of the colon.
5) Total form - lesions of the entire colon (sometimes - the distal part of the ileum).
B. Clinical stages:
1. Compensated.
2. Subcompensated.
3. Decompensated: acute and chronic.
Most often, the genesis of the disease is considered according to the criteria of polygenic
inheritance. Boys get sick much more often (according to various data - 4-5 and almost 9
times) than girls. It is believed that the cause of the disease is the inability of embryonic
nerve cells to migrate from the nerve crest to the wall of the primary intestine or the
inability of intramural and submucosal plexuses to develop together with the intestinal
wall in the caudal and cranial directions .
3. With what diseases it is necessary to carry out differential diagnosis?
Differential diagnosis: functional dynamic intestinal obstruction, meconium plug, stenosis of
the terminal ileum, functional constipation.
4. What additional special examinations should be performed to clarify the diagnosis?
Biopsy, p ectoanal manometry , ectromyography of the rectum .
Conservative treatment of constipation is carried out (if it is effective) until clinical and
laboratory confirmation of the diagnosis of Hirschsprung's disease .
In fact, the options for surgical tactics can be divided into two major groups:
- one-time radical surgical treatment (resection of the aganglionic zone);
Radical surgery involves resection of the aganglionic zone and part of the transition
zone . In recent years, minimally invasive methods of surgical treatment - TERT surgery -
have become increasingly common .
- imposition of temporary relief colostomy and postponement of radical surgical treatment.
The tactics of imposing a temporary discharge colostomy and delaying radical surgery
should be considered justified in cases of acute Hirschsprung's disease.
Task 39
The boy's parents, D., 7 months old, went to the hospital. The mother complains that the child has
occasional bouts of loud screaming and restlessness for the last 8 hours, in addition, 2 hours ago
there was vomiting without bile. Body temperature 37.3 0C.
From the anamnesis of life it is known: born from the first pregnancy without complications,
childbirth at 38 weeks, on the Apgar scale 8 points for 3 minutes, birth weight 3124 g, height 48
cm. Breastfed baby, supplementary feeding from 6 months of vegetables puree, yesterday for the
first time received semolina as a supplement. General condition of moderate severity. The skin is
pale, clean. Heart sounds are weakened, heart rate - 130 per minute. Breathing 31 per minute,
puerile, symmetrical. The abdomen is bloated, soft. An oval dense formation, 2-3 cm long, is
palpated in the upper right quadrant. There are no symptoms of peritoneal irritation. The liver is not
enlarged. Urine is intensely yellow. Stool last 9 hours ago, yellow, mushy.
Examination per rectum: perianal area without features, sphincter tone is normal, the
ampoule of the rectum is filled with a dark liquid content with impurities of blood and mucus.
Hemoglobin - 110 g / l; Er. - 3.1x 109 / l; k.p. - 0.86; Leukocytes - 12.2x109 / l; e - 1%; n -
8%; c - 66%; l - 22%; m - 3%; Platelets - 230x109 / l; ESR - 16 mm / year; pH 7.39; chloride - 99
mmol / l; bicarbonate - 28 mmol / l; potassium - 3.7 mmol / liter.
On the review roentgenogram of OChP in vertical position: pathology is not
revealed.
1. What is the disease?
Ileocecal intussusception of the intestine.
Etiology: common and long mesentery of the small and thick, physiological insufficiency of
the bauginian valve, uneven development of the longitudinal and circular layers of the
muscles of the intestinal wall with a predominance of circulatory muscles,
insufficiently differentiated nervous system of the intestine, nutrition, intestinal wall,
enlarged mesenteric lymph nodes, hematomas of the intestinal wall (for example, in
Shenlein - Henoch disease), hyperplasia of Peyer's patches, helminths.
Classification of acquired intestinal obstruction.
By morphofunctional features:
Dynamic intestinal obstruction
A) Spastic
B) Paralytic
Mechanical intestinal obstruction
A) Strangulation
B) Obturation
C) Mixed
By level of obstruction:
Small intestinal obstruction
A) High
B) Low
Colon obstruction
Over the course
Acute
Chronic
Recurrent
In addition, according to the degree of severity distinguish between complete and partial intestinal
obstruction. There are 3 stages of development of intestinal obstruction: 1 - stage of violation of the
passage of intestinal contents; 2 - stage of disorders of intramural intestinal hemocirculation; 3 -
stage of peritonitis.
3. What diseases should be included for differential diagnosis?
Differential diagnosis: dysentery, Meckel's diverticulum, abdominal syndrome in Shenlein-
Henoch disease (> 3 years), polyposis of the colon, colon prolapse,
4. What specific diagnostic methods should be used to clarify the diagnosis?
Ultrasound OChP (s-m target, s-m pseudonyrs), contrast irigography, pneumoirigography
5. What are the tactics of treatment of this patient?
CONSERVATIVE THERAPY
It is used in the first 18 hours after the onset of the disease or when the bleeding lasts no more
than 10 hours.
The intussusception is straightened with air at a pressure of 80 - 100 mm Hg. Art. At
inefficiency of conservative treatment and late terms of a disease surgical treatment is shown.
Task 40
In the maternity hospital 20 minutes after birth, the child was found to have a large amount of
foamy discharge from the mouth and nose. After suctioning, the mucus quickly accumulates
again. Shortness of breath and cyanosis are noted. Probing of the esophagus with an orogastric
catheter (Fr 8): the latter curled up, the end of which was found in the child's mouth. Body
temperature 37.0 0C. From the anamnesis of life it is known: the boy A. was born from the first
pregnancy, pregnancy without complications, physiological childbirth at 37 weeks, on the Apgar
scale 7 points for 3 minutes, weight at birth 2620, height 41 cm. Ultrasound after 20 weeks of
pregnancy did not pass. General condition of moderate severity. The skin is cyanotic, clean. Heart
sounds are weakened, heart rate - 140 per minute. Auscultatory in the lungs vesicular respiration,
determined by a large number of moist rales of various calibers. Respiration rate - 37 per
minute. The abdomen is swollen in the epigastrium, soft. Symptoms of peritoneal irritation are
negative. The liver is not enlarged. There was no urination or stool yet. Hemoglobin - 203 g /
l; Er. - 3.1x 109 / l; k.p. - 0.86; Leukocytes - 12.2x109 / l; e - 1%; n - 8%; c - 66%; l - 22%; m -
3%; Platelets - 230x109 / l; ESR - 16 mm / year; pH 7.39; chloride - 99 mmol / l; bicarbonate - 28
mmol / l; potassium - 3.7 mmol / liter. On the review radiograph of OGK and OCHP in a vertical
position: the probe is located at the level of Th-3, bent and returned to the oral cavity. Dilatation of
the stomach. The loops of the intestine are filled with gas.
1. What disease?
Esophageal atresia. Esophageal-tracheal fistula.
2. What is its etiology and classification?
Etiology
incorrect bookmark (formation) in the fetus of the esophagus in the period from 4 to 12 weeks of
fetal development. The trachea and esophagus of the fetus are formed from the cranial part of the
primary intestine and in the period of early embryogenesis are interconnected. Thus, atresia of the
esophagus occurs during their separation, which occurs with a violation of the speed and direction
of growth of the esophagus and trachea, with incomplete separation of the esophagus from the
trachea and disruption of its supply. In addition, the pathology occurs due to a violation of the
recanalization process, which affects all branches of the intestinal tube.
Classification
Esophageal atresia in children is fistulous and isolated . Fistula artesia involves a combination
with a tracheoesophageal fistula, and isolated - without a connection with the trachea.
Typical forms of this pathology are:
- atresia with a fistula between the trachea and the distal part of the esophagus (80-90%);
- atresia with a fistula between the trachea and the proximal part of the esophagus (about 1%);
- atresia with a fistula between the trachea and the two ends of the esophagus (up to 0.5%);
- isolated atresia of the esophagus without fistula (6-7%)
3. What diseases should be included in the differential diagnosis?
esophagospasm, esophageal stenosis, laryngeal cleft, isolated tracheoesophageal fistula, congenital
pylorostenosis
4. What specific diagnostic methods should be used to clarify the diagnosis?
Immediately after birth:
1. Probing of the esophagus with a rubber catheter (N 8 - 10) - there is an obstacle to the probe
through the esophagus.
2. Foamy discharge from the mouth and nose.
3. Cyanosis.
4. Injection into the air probe (Elephant test) - the air introduced into the probe with noise returns
to the outside.
5. Percussion of the abdomen - tympanitis over the stomach.
6- review radiography of the chest in two projections with the introduction of a probe into the oral
end of the esophagus
In the surgical department:
1. Review radiography of the thoracic and abdominal organs.
2. X-ray examination of the esophagus with an X-ray contrast probe.
3. Ultrasound examination of the abdominal and thoracic organs (for the presence of concomitant
malformations).
4. Neurosonography.
5. Echocardiography and ultrasound of large vessels.
6. Consultation of a geneticist.
5. What are the tactics of treatment of the newborn?
-Preoperative preparation
-surgical treatment of
early surgery. First: 1) aspirate the contents of the nasopharynx and oropharynx every 15-20
minutes; 2) oxygen therapy; 3) complete exclusion of oral feeding; 4) direct laryngoscopy with
tracheal catheterization and aspiration of contents from the respiratory tract; 5) bronchoscopy or
intubation of the trachea with thorough aspiration.
At a fistula it is expedient to begin with a thoracotomy and division; if the diastase between the
ends of the esophagus is not more than 1.5-2 cm, then impose a direct anastomosis, if it exceeds -
impose a cervical esophagostomy and gastrostomy on Kader. After the operation - feeding through
a tube, for 6-7 days examine the ability of the anastomosis (under Rg-kym control through the
mouth is injected 1-2 ml of contrast in-va), after 2-3 weeks failed control FEGS, if the narrowing
of the esophagus is detected - buzzing. After esophago- and gastrostomy, children aged 2-3
months to 3 years perform esophageal plastic surgery with a colon graft.
Task 41
The boy is 6 months old. The parents noticed that the child did not have a left testicle. During the
examination of the child and genitals, physical development corresponds to age. The right testicle
in the scrotum, the left half of the scrotum is underdeveloped, the testicle is absent, during the
inguinal canal palpable rounded formation of 1.2x1.0 cm.
1. Your diagnosis?
Left cryptorchidism. Ectopia of the left testicle?
2. What diagnostic steps do you take to confirm the diagnosis?
- The main method of diagnosing cryptorchidism is a physical examination, the results of which
determine the presence of: 1) unilateral or bilateral cryptorchidism; 2) localization of the
undescended testis (palpable location, not palpable) and the degree of its mobility. Palpation of the
testicle is performed bimanually in the position of the patient lying and standing.
-UZD
-Laparoscopy
-hormonal diagnosis (consultation with an endocrinologist)
3. What diseases need to be differentially diagnosed?
Femoral hernias, inguinal, genetic abnormalities
4. What method of treatment do you prescribe and the term of its implementation?
The undescended testicle is erected in the scrotum. The operation is performed early due to the
danger of various complications due to the abnormal location of the testicle - at the age of 1-2
years.
In the case of severe endocrine disorders - Hormonal treatment, which in some cases leads to
lowering of the testicle without surgery.
At an ectopia the testicle is allocated from surrounding fabrics and lowered in a scrotum, We fix
for covers to tunica dartos (Schuller's operation). In cryptorchidism, the erection and fixation of
the testicle (orchypexia) is carried out by the method of two-stage erection of the testis by
laparoscopy to avoid damage to the vessels of the spermatic cord.
Treatment of cryptorchidism is mainly surgical, under certain conditions conservative treatment is
allowed. Conservative treatment begins (the use of gondotropin, multivitamins) in cases of false
cryptorchidism, with the localization of the testicles near the outer opening of the inguinal
canal. The duration of treatment is 6 - 8 months.
INDICATIONS FOR SURGICAL CORRECTION OF CRYPTORCHISM:
- all types of testicular ectopia;
- combination of cryptorchidism with inguinal hernia;
- complications of cryptorchidism (torsion or pinching of the spermatic cord);
- ineffectiveness of conservative treatment.
DEADLINES. According to WHO recommendations, cryptorchidism treatment should be
completed by the age of 2.
Surgical treatment consists in lowering the testicle that has not descended into the scrotum
surgically - the general name of the operation - "orchypexia" or "lowering the testicle into the
scrotum."
The final stage of orchypexia is the fixation of the testicle in the scrotum. Among the methods of
fixation, preference should be given to non-traction techniques (such as Petrivalsky - Shoemaker,
etc.). Testicular fixation using different traction options (fixation to the thigh skin, creation of the
scrotal-femoral cuff, etc.) should not be used as those that contribute to testicular atrophy. In cases
when it is technically impossible to move the testicle to the bottom of the scrotum (intraperitoneal
cryptorchidism, etc.) without the tension of the spermatic cord, the operation is performed in 2
stages:
- 1 stage - the testicle is moved outside the outer ring of the inguinal canal;
- Stage 2 - moving the testicle to the bottom of the scrotum is performed in 10 - 12 months after
stage 1.
Task 42
A 6-month-old child is in a somatic hospital due to left-sided pneumonia. In the anamnesis - left
inguinal-scalp hernia, there were no pinches before. For two hours there was a protrusion of the
hernia, which the mother could not insert into the abdominal cavity.
1. What are the tactics of the doctor on duty?
Conservative treatment.
2. What is medical care?
Antispasmodics, painless therapy, lift the lower end of the child's torso.
3. Further tactics of hernia treatment
Operative intervention in a planned manner.
4. What anatomical premise leads to inguinal hernia in children?
Non-overgrowth of the vaginal appendix of the peritoneum (normally up to 6 months).
Task 43
The boy is 12 years old for a week of abdominal pain, fever up to 38.50C, in the analysis of urine -
leukocyturia, proteinuria. On ultrasound - the expansion of the pelvic system of the left kidney.
1. Your diagnosis?
Left-side hydronephrosis, acute piyelonefr and so on.
2. What additional examination methods are needed to clarify the diagnosis?
Excretory urography, urinary cystography, radioisotope renography.
3. The main causes of the disease.
Congenital causes - aberrant vessel, embryonic cords, narrowing of the pelvic-
ureteral segment. Acquired causes - urolithiasis.
4. Clinical manifestations.
At the beginning of the disease there is no clinic.
5. Treatment plan.
Restoration of urine outflow, antibacterial therapy, uroseptics, surgical treatment
after preoperative preparation .
Task 44
A 5-year-old child from the age of 3 periodically has cramping abdominal pain, vomiting,
accelerated urination, fever up to 38oC and more. There are no catarrhal phenomena, the chair is
normal. In the clinical analysis of urine - leukocyturia, bacteriuria. At micturition cystography the
expanded ureter was filled.
1. Formulate a diagnosis.
Vesicoureteral reflux. Chronic pyelonephritis, recurrent course.
2. What are the additional methods of examination?
Renal ultrasound, excretory urography, urinary cystography.
3. With what diseases it is necessary to carry out differential diagnosis.
Urolithiasis, gastritis, worm infestation.
4. Treatment tactics.
Table №5, antibacterial therapy course up to 6 months, phytotherapy. In the absence of the
effect of antireflux surgery, endoscopic delivery of the gel into the bladder.
Problem 45
At the boy of 1,5 years there is an increase in the sizes of the right half of a gate. Enlargement of the
scrotum from birth. The mother notes an increase in education in the evening and a decrease in the
morning. Palpable soft-elastic formation, painless. At a diaphanoscopy - all right half of a gate is
translucent evenly.
1. Your diagnosis.
Hydrocele (hydrocele)
2. Treatment tactics.
Waiting tactics up to 2 years.
3. What additional instrumental method helps in diagnosis?
a) transillumination or diaphanoscopy;
b) Ultrasound of the scrotum and groin.
4. Until what age are children with this pathology not operated on?
Up to 2 years.
5. Differential diagnosis.
Differential diagnosis of hydrocephalus is performed with inguinal hernia (including one
that has a pinch), with tumors of the scrotum and testis.
Task 46
The boy is 4 years old - swelling and redness of the foreskin, pus. The head of the penis does
not open, the foreskin is narrowed.
1. Your diagnosis :
Physiological phimosis? Catarrhal fasting?
2. Probable etiology:
- fungus of the genus Candida , streptococcus, bacteroid, gardnerella;
- failure to observe personal hygiene;
- poor foreskin motility;
3. Your treatment tactics?
- treatment of the inflammatory process: general - antibiotic therapy (cefazolin / cephalexin - 25
mg / kg 2 times / day). Topical - baths with chlorhexidine, furacillin or a weak solution of
potassium permanganate.
- operative: circumcision (excision of the foreskin along the rim, the bridle is cut, and the foreskin
is removed; the edges of the tissue are sutured with self-absorbing material. Surgery is performed
under general anesthesia)
4. The most common complications in the removal of the head of the penis in a child with
phimosis.
The most common complications in the removal of the glans penis in a child with phimosis are
paraphimosis and balanoposthitis.
Task 47
A 13-year-old boy was taken by his parents to the admission department of the hospital with an
injury: the first and second fingers of the right hand were affected - the distal phalanges were bluish,
small blisters on the middle phalanges. Objectively: the general condition is satisfactory. He did not
suffer from chronic diseases. He did not come into contact with electrical appliances. It is known
that an hour before that, he was playing outside and pinched his hand with a sledge, then he carried
the sledge home for a long time so that his parents would release their hand. On the street strong
wind, air temperature -5oC.
1 . What is the patient's injury?
Frostbite of the II degree.
2 . Classification of this type of lesions?
This type of damage is attributed to damage caused by low temperatures and is classified
according to the degree of impression: there are IV degree of external manifestations and clinical
picture.
3 . Assign a set of urgent measures in this cas e?
Immediate, but GRADUAL warming up of the victim: to place in a warm room, very warm
warming drink (tea, coffee, milk). Apply a warm local bath for the injured hand ( t 20 C with a
gradual increase from 20C - 40C and wash with soap from dirt), apply an aseptic bandage of gauze
bandage or cotton cloth.
4 . Prevention of this type of lesion?
Wear loose clothing (normal blood circulation is not disturbed), do not forget to take gloves for
walks, change clothes in time if wet, dose the time of walks (if you feel hypothermia or freezing -
return to a warm room); avoid walking in windy weather (the probability of frostbite is much
higher)
Task 48
Patient M, 23 years old, 2 days ago was injured at home in a state of intoxication. According to the
patient, he slept indefinitely on the street at an air temperature of -3ºC in wet shoes. He did not seek
medical help. The condition of the patient is moderate. On the feet the nail phalanges are
mummified, the feet and lower thirds of the legs are bluish. Complaints of numbness in the feet,
shortness of breath. On auscultation: vesicular respiration, weakened in the lower parts on both
sides.
5. Establish a basic diagnosis?
Cold injury. Frostbite of the lower extremities of III degree in the area of feet and ankles.
6. What additional pathology do you suspect in the patient?
Pneumonia.
7. Assign a set of laboratory and instrumental examinations and specialist consultations?
General blood test, clinical blood test, coagulogram, biochemical blood test, determination of blood
group and Rh factor, general urine test, blood sugar test, body t , ultrasonography of the lower
extremities, radiography of the lower extremities, OGK radiography.
Surgeon, cardiologist, pulmonologist.
8. Identify the main areas of treatment of the patient?
Prehospital stage: heat-insulating bandages, immobilization of the lower extremities. Hospital stage:
infusion therapy - hypertonic solutions of crystalloids (7.5% sodium chloride solution) bolus 4-6 ml
/ kg for 3-5 minutes, followed by infusion of heated glucose solutions (5% ≈ 300.0) Ringer-Locke
solution ≈ 500.0. Vasodilators: pentoxifylline, tren tal, dibazole, nicotinic acid. Anticoagulants:
fraxiparin, fragmin, klexan.
Specialized care: surgery - removal of non-viable tissues (exarticulation or amputation of limbs).
Task 49
A 42-year-old patient V., who had damaged a high-voltage electric cable at work, was taken to
the hospital's admission department by an ambulance . The patient lost consciousness for several
minutes. On examination: pale skin, right hand and forearm in a state of flexion, sharp swelling of
the affected limb. In the elbow fossa and lower part of the forearm - necrotic scab black, 10x12 cm
in size. Fingers in a state of flexion, cold, severely swollen.
5. Establish a preliminary diagnosis? Classification of this type of lesions. Mixed electric
shock.
Occupational injuries, electric shock Istupen, electric burn IIIb degree.
6. In which department should the patient be hospitalized?
In the burn department.
7. Indicators of monitoring the patient's condition?
Blood pressure, heart rate, BH, SpO 2, daily diuresis, body t , ECG.
8. Determine the tactics of surgical treatment?
Opening of blisters, removal of necrotic tissues with subsequent autoplasty.
Problem 50
Patient N., 34 years old, applied to the burn department with complaints of skin lesions of both
hands, sharp pain and a feeling of heartburn in them. According to the patient, about 2 hours ago
she spilled an unknown liquid on the brush to clean the sewer pipes. On examination: the skin of
both hands is moderately swollen, moist, gray, limited redness around.
1. What type of lesion can be suspected in a patient ?
Chemical burns.
2. Characteristics and classification of this type of lesions.
Chemical burns are caused by alkali. Formed of ' who, wet, white and gray, slightly soapy to the
touch crust. Colicative necrosis of tissues develops.
Domestic trauma. Limited, external chemical burn of the II degree is caused by the action of alkali.
3. First aid for this type of lesion.
Stop the chemical factor. Rinse under running water for 15-20 minutes. Treat with 2 % acetic acid
solution. Apply aseptic floor ' connection.
4. Tactics of surgical treatment of this type of lesions.
Alkali burns are deep. Surgical treatment is to remove dead tissue in 3-4 weeks when the burn scab
is rejected and the depth of necrosis can be assessed. In the future, autoplasty of tissues is
performed.
Problem 50
Patient N., 34 years old, applied to the burn department with complaints of skin lesions of both
hands, sharp pain and a feeling of heartburn in them. According to the patient, about 2 hours ago
she spilled an unknown liquid on the brush to clean the sewer pipes. On examination: the skin of
both hands is moderately swollen, moist, gray, limited redness around . 1. What type of lesion can
be suspected in a patient? 2. Characteristics and classification of this type of lesions. 3. First aid for
this type of lesion. 4. Tactics of surgical treatment of this type of lesions
1) Chemical burns.
2) Chemical superficial burn. 1 degree. Defeat by alkalis
3) R eteln is washing I burn surface water under some pressure until flushing 8 chemical
substance (disappearance of the smell) . In case of alkali burns, washing is performed
with sodium bicarbonate solution. After washing, the burn surface is covered with a
bandage soaked in a neutralizing substance
4) If the burns are deep, especially with dry necrosis, make an early necrotomy (incision of
the scab), partial necrectomy and, after wound preparation, autodermoplasty.
Problem 51
Patient B., 62, who was injured 2 weeks ago, is being treated in the burn department. Diagnosed
with IIABA flame burn. lower extremities, perineum, external genitalia, buttocks, front surface of
the torso, hands and forearms 45 (30)% p.t. Burn disease, severe. The patient underwent early and
necrectomy with one-stage partial autodermoplasty. About 10% of the pt remains uncovered, the
skin flaps do not take root well. Objectively: the general condition is severe, consciousness is
confused. Above the lungs during auscultation hard breathing. Heart tones are deaf. Diuresis 800 ml
/ day, t - 39.2oC; CDR - 20 / min; AT-90/60 mm Hg; Pulse - 106 / min. Laboratory: Hb - 84 g /
l; Er. - 2.34x1012 / l; L - 15.8x109 / l; total protein - 52 g / l; creatinine 150 μmol / l; uric acid - 460
μmol / l.
1. What is the stage of burn disease in a patient?
2. What are the burn diseases?
3. What tests should be prescribed to the patient?
4. What is the most dangerous complication of burn sepsis?
Answer:
1. Burn shock. Severe. The patient's condition corresponds to the third stage of burn disease - burn
septicotoxemia (from the 13th day until the restoration of the skin);
2. In the clinical picture of burn disease there are four periods: - And - burn shock (24-72 hours); -
ІІ - acute burn toxemia - 3rd – 12th day); - III - burn septicotoxemia (from the 13th day until the
restoration of the skin); - And V - convalescence (from the restoration of the skin to the restoration
of the functions of organs and systems).
3. ZAK, Bh an. Cr, daily diuresis, smears from the affected skin for microbiological examination.
4. This is a multi-organ pathology manifested by impaired hemodynamics, respiration, metabolism,
kidney and liver function. There are significant metabolic disorders: acidosis, changes in the
calcium-potassium index due to hyperkalemia, increased proteolytic activity of the blood,
accumulation of histomine-like substances, tissue breakdown products, decreased energy
components and vitamins. Deterioration of kidney function leads to a delay in the body's metabolic
products and endotoxins, which adversely affects the condition of the victims. At the same time
there is a decompensation of the function of the endocrine glands, especially the adrenal glands,
which is manifested by acute adrenal insufficiency. Toxemia, hemodynamic disturbances and
respiration adversely affect liver function.
Task 52
A 43-year-old woman had an 18-year history of nodular goiter with a slow rate of enlargement on
the front of her neck. Previously, she noted any symptoms, but in the last 2 months there were signs
such as discomfort, compression, dysphagia, shortness of breath and hoarseness. At physical
inspection of a thyroid gland at the patient the right soft elastic knot in the size more than 10 mm is
palpated.
Laboratory tests: TSH-2.1 (control range, 0.4 mO / l to 4.0 mO / l), T4 free - 13 mmol / l, antibodies
ATPO, ATTG were negative.
Additional research methods: CT of the neck revealed a solitary dominant node of the right lobe of
the thyroid gland with a size of 140 × 78 × 84 mm without invasion of neighboring
structures. There was also a slight compression and deviation of the left trachea. Ultrasound of the
thyroid gland confirmed the presence of a heterogeneous tumor, isoechoic, with a cystic component
and with indistinct contours, which occupies the entire right lobe of the thyroid gland. The left lobe
also has a hypoechoic nodule of 0.8 cm. After thyroid TAPB cytologically established the presence
of follicular cancer of the right lobe and the benign nature of the left lobe.
1. Choose and justify surgical tactics: left hemistrumectomy, subtotal thyroidectomy or total
thyroidectomy?
2. Is the use of radioactive iodine I 131 justified? What are the principles of suppressive L-
thyroxine therapy?
3. How is thyroid cancer classified?
4. Compare the features and prognostic value of metastases of follicular and papillary thyroid
cancer?
Answer:
1. Total thyroidectomy, due to the presence on ultrasound examination of a heterogeneous tumor,
isoechoic, with a cystic component and with indistinct contours, occupying the entire right lobe of
the thyroid gland and involvement in the process of the left lobe of the thyroid gland.
2. The appointment of radioactive iodine 131 is justified in the first 4-6 weeks after surgery due to
the ability of tumor tissue to absorb and retain radioactive iodine, and radiation destroys the tissue
that has accumulated I-131.
Principles of suppressive therapy: 1. The dose of L -thyroxine after total thyroidectomy is
approximately from 2.0 to 3.0 μg / kg / day. 2. Elderly patients with pathology of the cardiovascular
system are sometimes unable to prescribe the required dose of hormone for suppression. 3. The
effectiveness and dose adjustment of L -thyroxine is monitored directly by measuring the level of
TSH in 6-8 weeks from the start of hormonal treatment. 4. At the same time the level of free T3 and
T4 is determined. Patients with a high risk of recurrence, with disease persistence, as well as with
the level of TG determined ( 2 ng / ml), patients at high risk of recurrence in the absence of
signs of persistence / recurrence of the disease for 3-5 years after remission dose L - thyroxine
should reduce the level of TSH to 0.1 mm O / l at normal values of free T 3 and usually slightly
elevated levels of free T4. Patients from the group of moderate risk of recurrence should use an
individual approach. In patients at low risk in the absence of signs of persistence / recurrence of the
disease, the level of TSH may be within the lower level of reference values (0.4-1.0 mIU / l).
3. Classification of thyroid cancer: * Morphological classification of thyroid cancer. 1st type A -
highly differentiated: 1) papillary - grows slowly, metastasizes mainly to the lymph nodes of the
neck, 2) follicular - grows slowly, metastasizes mainly hematogenously to the bones and
lungs. Type 2 of C cells (APUD cells): A) medullary - 25% is familial cancer B) undifferentiated
* according to the TNM system T1 - <1 cm T2 - from 1 to 4 cm, T3 -> 4 cm but within the capsule
of the thyroid gland, T4 - the tumor moves to neighboring anatomical structures. N0 - regional
metastases are absent; N1 - metastases to regional lymph nodes. M0 - no distant metastases M1 -
there are distant metastases. Grouping by stages of thyroid cancer Any spread of the process in
undifferentiated form of thyroid cancer is 1U Art.
Problem 53
A 42-year-old woman had a history of grade 3 thyroid enlargement with thyrotoxicosis diagnosed 2
years ago. Thyroid profile (TSH, T4free, T3free) were normal on the background of constant use of
mercazolyl 10 mg per day. Serum calcium, vitamin D, phosphorus and PTH were also within
normal limits.
The patient underwent a total thyroidectomy, with a histological conclusion: multinodular goiter.
Two weeks after thyroidectomy, there were daily numerous seizures in the upper extremities lasting
up to 30 minutes each episode.
Laboratory tests: TSH - 2.0 (normal values 0.4 - 4.0 mO / l), total calcium level - 3 mg / dL (normal
values, 8.6-10.2 mg / dL) and PTH - 6 , 1 pg / ml (normal values, 15–65 pg / ml), 25-vitamin D-OH
32 ng / ml (normal values up to 30 ng / ml).
1. Establish and justify the diagnosis (pre- and postoperative).
2. Should I stop treatment with antithyroid drugs before surgery?
3. What treatment should be prescribed immediately?
4. Does the patient need to take any medication in the future? Write recipes, if so.
1. DS : preoperative - Nontoxic dash yidnyy multynodulyarnyy goiter, postoperative -
postoperative g ipoparatyreoyidyzm .
2. no, you do not need to stop treatment.
3., 4. It is necessary to appoint L -thyroxine. The dose of L -thyroxine after total thyroidectomy is
approximately from 2.0 to 3.0 μg / kg / day.
Problem 54
A 23-year-old woman complains of sharp pain in the front of her neck and an asymmetrical
enlargement of her left side that appeared two days ago. The thyroid gland is painful on palpation
with irradiation of pain in the lower jaw, left ear. Body temperature - 37.8 ° C. The patient suffered
from SARS 2 weeks ago.
Clinical blood test - ESR - 48 mm / h, L - 8x109 / liter.
Ultrasound of the thyroid gland: right lobe V = 6.4 cm3; moderate increase in the left lobe V = 9.8
cm3; parenchyma of unevenly reduced echogenicity with anechoic area without clear contours; at
research in the mode of color Doppler - absence of color spikes; right lobe - diffusely isoechoic.
1. Establish and justify the diagnosis. What additional methods are needed to confirm the diagnosis?
2. How is subacute thyroiditis different from acute thyroiditis?
3. Does the patient need urgent thyroid surgery?
4. What is the size of the thyroid gland in nodular goiter is considered an indication for surgery?
1. DS : subacute thyroiditis de Quervain to whom indicates nerovnomirno
lowered and echogenicity b of anehohennoyu area without clear contours parenchyma thyroid
ultrasound examination. Auxiliary researches : Laboratory researches: 1) ESR - considerably
accelerated (accompanies pain of a thyroid gland); 2) TSH and thyroid gland; 3) antithyroid
antibodies can be detected (only in 10–20% of patients, more often anti-TG than ATPO), but they
do not play a role in etiopathogenesis. Imaging studies: ultrasound of the thyroid gland - diffuse
or focal hypoechogenicity of the thyroid gland. Thyroid scintigraphy is an extremely low iodine
storage capacity (in the first phase of the disease). Cytological examination: neutrophils
with characteristic giant cells (multinucleated macrophages), as well as with histiocytes
(mononuclear macrophages) predominate .
2.
Disease Similar Distinctive features Additional
manifestations features
Blood test Ultrasound Cytological
signs
Acute non- Pain in the Increase in the Total _ In the
purulent gland, fever content of hypoechogenicity anamnesis of
thyroiditis thyroid of the gland treatment
hormones with
radioactive
iodine or its
excessive
intake in
extreme
situations
Subacute Pain in the In the general Heterogeneity of Clusters of _
thyroiditis gland, fever analysis of echostructure due histiocytes and
blood - to a large number giant cells
increased ESR, of small and
absence of medium hypo or
leukocytosis anechogenic
and changes in inclusions
the blood
formula
3. No, not required. For the purpose of treatment Acetylsalicylic acid 2–4 g / day is prescribed for
the purpose of anesthesia and anti-inflammatory treatment, or NSAIDs, e.g. ibuprofen ; in case of
severe pain, as well as if prescribed in a full dose of drugs do not control pain for several days
→ use prednisone 40-60 mg / day for 1 week, or 40 mg / day for 2 weeks, gradually reduce the dose
, on average by 5–10 mg / week. The use of HA does not reduce the risk of hypothyroidism, but it
relieves pain and usually leads to faster resolution of symptoms. The hyperthyroid phase does not
require antithyroid treatment ( propranolol can be used ) . In the phase of hypothyroidism, consider
the need for L - T 4 (prevents exacerbation of the disease); It should be remembered that
hypothyroidism is temporary and there is no need for continuous therapy (it is necessary to cancel
the drug after 3-6 months and assess thyroid function). Surgical treatment is a mistake - the disease
goes away on its own and does not lead to permanent damage to the thyroid gland.
4. Indications for surgical treatment of nodular goiter
 - the presence of a node larger than 3 cm;
Problem 55
A 20-year-old man has a fever (39 ° C), tachycardia, sweating, pain
in the throat, weakness, swelling of the anterior surface of the neck, local erythema,
dysphagia, weight loss. Palpation of the thyroid gland is accompanied
acute pain and irradiation to the left lower jaw and left ear.
Laboratory tests: the amount of blood - ESR - 18 mm / h, L - 12x109 / liter.
TSH - 0.01 mO / l (0.4 mO / l to 4.0 mO / l).
Ultrasound of the thyroid gland - the size of the thyroid gland: right lobe V = 9.4 cm3; left lobe V =
9.6 cm 3. IN
the left lobe is determined by an anechogenic locus of the parenchyma measuring 28x22 mm.
Doppler picture of the "cold node".
1. Establish and justify the diagnosis. What additional methods are needed for
confirmation of the diagnosis?
2. What additional methods are needed to confirm the diagnosis?
3. What surgery should be prescribed?
4. Should I prescribe antithyroid or thyroid replacement therapy
bets?
1. Thyroid cancer.
2. Ultrasound examination of the neck, which allows to identify malignant neoplasms from 3 mm in
the largest diameter.
Fine-needle aspiration puncture biopsy (TAPB), which can be used to obtain malignant cells and
evaluate them by microscopy.
Conducting an open biopsy with rapid pathological examination (EPGD) in non-informative
TAPB. Routine use of EPGD allows to clarify the diagnosis of thyroid cancer during surgery.
Determination of tumor markers: Cancer-embryonic antigen, calcitonin - effective only when
medullary cancer is suspected. For the rest of the thyroid gland - no diagnostic marker.
Additional tests to verify the diagnosis or relapse
Computed tomographyTc-99m-MIBI is a radiopharmaceutical that can detect radioiodine-sensitive
metastases
Positron emission tomography
3. Surgical treatment
Carried out in all cases. Thyroidectomy and neck dissection are performed. The radical scope of
surgical treatment significantly improves survival, quality of life and the absence of recurrence of
thyroid cancer.
Adjuvant radioiodine therapyEdit
The goal of postoperative adjuvant radioiodine therapy (RTI) is to destroy thyroid cells that may
have remained after thyroidectomy.
4. After surgical removal of the thyroid gland, patients are prescribed hormone replacement therapy
(levothyroxine) for life. In medullary or anaplastic thyroid cancer, the dose required to maintain
thyroid-stimulating hormone (TSH) is normal. In papillary or follicular cancer, as well as in one of
their subtypes, the dose of thyroid hormone is selected to maintain TSH at a level corresponding to
the risk of persistence or recurrence of the disease in each individual case.
Task 56
A 34-year-old man was admitted to the clinic with a sudden onset of left-sided swelling of the neck,
accompanied by pain and redness. In the anamnesis the patient did not note a chronic disease,
upper respiratory tract infection or injury. The node of the left lobe of the thyroid gland was
palpated.
Clinical blood test: monocytes 15 × 106 μl (0–9.0 × 106), ESR - 52 mm / h (<15 mm / h) and the
level of C-reactive protein (CRP) - 14.2 mg / dl (0 –0.5). Thyroid hormones are normal. Ultrasound:
size of the thyroid gland: right lobe V = 7.8 cm3; left lobe V = 8.6 cm 3. In the left lobe is defined
anechogenic area of the parenchyma size of 12 × 9 mm with cystic contents, and enlarged regional
lymph nodes.
1. Make a differential diagnosis between subacute de Kerwein's thyroiditis and acute purulent
thyroiditis.
2. Specify the diagnostic criteria used to verify the diagnosis.
3. What are the principles of surgery in this patient? Describe the sequence of treatment steps.
4. What method can be used to ensure microbiological identification in this case?
1. Differential diagnosis of thyroiditis
Disease Similar Distinctive fe atures Additional
manifestations features
Blood test Ultrasound Cytological
signs
Acute non- Pain in the Increase in the Total hypoechogenicity _ In the anamnesis
purulent gland, fever content of of the gland of treatment with
thyroiditis thyroid radioactive iodine
hormones or its excessive
intake in extreme
situations
Subacute Pain in the In the general Heterogeneity of Clusters of _

thyroiditis gland, fever analysis of echostructure due to a histiocytes
De blood - large number of small and giant
Kerwein increased ESR, and medium hypo or cells
absence of anechogenic inclusions
leukocytosis
and changes in
the blood
formula
Hemorrhage Acute onset, Increased ESR _ _ Enlarged, fixed
in the cyst enlarged and gland, immobile
of the painful gland, on palpation
thyroid fever
gland
Febrile Increased in _ Reduced echogenicity, Signs of The presence of
form size, painful echostructure malignancy malignantly
of thyroid on palpation of polymorphism, fuzzy transformed cells
cancer the contours, microcalcinates in the punctate
gland; fever
2. The diagnosis is reliable in the presence of both main criteria and two arbitrary additional
criteria:
1) the main criteria - soreness or hypersensitivity of the goiter on palpation; ESR acceleration;
2) additional criteria - significantly reduced iodine accumulation capacity, transient
hyperthyroidism, typical for subacute thyroiditis picture on ultrasound, picture with TAPB typical
for subacute thyroiditis, absence or low level of antithyroid antibodies.
3. Surgical treatment is a mistake - the disease goes away on its own and does not lead to
permanent damage to the thyroid gland. The hyperthyroid phase does not require antithyroid
treatment ( propranolol can be used ). For the purpose of anesthesia and anti-inflammatory
treatment, acetylsalicylic acid is prescribed 2–4 g / day, or NSAIDs, e.g. ibuprofen ; in case of
severe pain, as well as if prescribed in a full dose of drugs do not control pain for several days
→ use prednisone 40-60 mg / day for 1 week, or 40 mg / day for 2 weeks, gradually reduce the dose
, on average by 5–10 mg / week. The use of HA does not reduce the risk of hypothyroidism, but it
relieves pain and usually leads to faster resolution of symptoms.
In the phase of hypothyroidism, consider the need for L-T4 (prevents exacerbation of the
disease); It should be remembered that hypothyroidism is temporary and there is no need
for continuous therapy (it is necessary to cancel the drug after 3-6 months and assess thyroid
function).
4. Cytological examination: neutrophils with characteristic giant cells (multinucleated
macrophages), as well as with histiocytes (mononuclear macrophages) predominate .
Problem 57
In a 57-year-old patient a month after palliative subtotal gastrectomy, there is a shortening of the
percussion sound in the abdomen and displacement of the "percussion dullness" when changing
body position. The abdomen is sharply increased in size, during laparoscopy it was found that the
parietal and visceral peritoneum is affected by small prosodic screenings. What complicated the
course of the disease in the patient? What treatment measures are indicated for this patient in order
to improve his condition?
Answer: Peritoneal carcinoma, ascites. Intraperitoneal chemotherapy, laparocentesis, diuretics,
tonic therapy.
Problem 58
Patient R., 60 years old, went to the doctor with complaints about the presence of a sigmostoma,
from which there is excessive gas and frequent diarrhea. From the anamnesis it is known that the
woman underwent surgery for 3 months for rectal cancer.
Question:
What diet will be most appropriate to prevent flatulence and provide a denser consistency of stool in
this patient?
Answer standard:
Diet low in crude fiber, apple juice, boiled rice, pasta, potatoes, white bread, bananas, cheese.
Task 59
Patient M., 57 years old, complained of shortness of breath, cough, which sharply increase
immediately after eating. Six months ago, the patient was diagnosed with squamous cell carcinoma
of the middle thoracic esophagus. At the same time the patient underwent a course of remote
gamma therapy. For carrying out a surgical stage of the planned combined treatment didn't appear.
What complication arose at the patient? What is the main method of palliative care?
Answer: Esophageal -tracheal fistula. Formation of gastro- or entorostomy.
Problem 60
X thief P., 70 years old, a month after the transversostomy was applied to a doctor with complaints
of itching and moderate burning pain in the stoma. On examination, the skin around the intestine
brought to the anterior abdominal wall is hyperemic, macerated with multiple superficial
erosions. What complication did the patient have? What are the remedies for the treatment and
prevention of this complication?
Answer:
D ermatyt due to irritation of the mucus and feces intestine. Treatment of skin with water-based
antiseptic solutions (furacillin solution, decane), application of protective and stimulating
epithelialization ointments (zinc, desitin, methyluracil, solcoseril, Lassara paste), talcum powder,
protective bandages.
Task 61
Patient B., 59 years old, complained of intermittent vomiting of remnants of poorly digested food,
discomfort in the epigastric region, weight loss of 9 kg over the past month, loss of appetite and
moderate general weakness. Endoscopically, the patient had an infiltrative-ulcerative lesion in the
area of the cardiac department and the body of the stomach along the posterior wall of the organ
with a transition to a small curvature. Histologically - undifferentiated carcinoma. During
laparotomy, it was found that the tumor of the stomach spreads to the extraperitoneal space,
immobile. The anterior wall of the stomach is intact. In the liver - a dense metastatic node 3x3 cm.
Question:
What is the amount of surgery shown to this patient?
What is the type of operation according to the oncological classification of surgical interventions?
Answer standard:
The imposition of a bypass gastro-eunoanastomosis is shown. Symptomatic surgery
Task 62
Patient D., 45 years old, went to the doctor with complaints of recurrent headaches, vomiting from 6
to 10 times a day, not related to food intake. From the anamnesis it is known that 12 months ago the
man was operated on about pigmented melanoma of the skin of the back. According to the results of
histological conclusion, the depth of tumor invasion was 8 mm. According to the results of a week-
long computed tomography in the right hemisphere of the brain, the patient was found to have a
volumetric focus measuring 4x4x4 cm.
Question:
What is the most likely diagnosis in a patient?
What are the treatment tactics and the amount of medical care to alleviate the patient's condition?
Answer standard:
Melanoma of the skin of the back, the condition after surgery. Metastatic brain damage. Active
dehydration therapy aimed at decompression of the brain: restriction of fluid intake, the
appointment of glucocorticoids (dexamethasone up to 16-20 mg / day) and the introduction of
diuretics osmotic action (10-20% mannitol solution 2 g / kg). At symptoms of the expressed
dehydration after application of a solution of mannitol water balance is restored by drop infusions
of isotonic solution of sodium chloride, for improvement of venous outflow to the patient give the
raised position, performance of a lumbar puncture is possible.
Problem 63
Patient M., 53 years old, complains of pain in the lumbar spine, which bothers about 6 months. At
examination of the patient in the oncological dispensary 2 months ago the diagnosis of cancer of the
right kidney was established and surgical treatment - a right nephrectomy was carried out. After the
operation, no pronounced negative neurological dynamics was noted, the pain gradually increased
slowly. At X-ray inspection of a backbone the extensive center of destruction in a vertebral body L4
is established. What is the most probable diagnosis at the patient? What are the treatment tactics and
the amount of medical care to alleviate the patient's condition?
Answer: Cancer of the right kidney, condition after surgery. Metastatic lesion of the L4
vertebra. Compression pain syndrome. Given the solitary nature of the lesion, relatively favorable
prognosis, low sensitivity of the tumor to special treatment, the patient is indicated for surgical
treatment in the amount of L4 vertebral correctomy with anterior decompression of the dural
sac. After the operation, immunotherapy and radiation therapy on the bed of the removed vertebra
are indicated.
Task 64
Patient G., 49 years old, 4 months after undergoing combination therapy for breast cancer (radiation
therapy to the right axillary area + right mastectomy) complained of edema, limited mobility, a
feeling of distension and itching of the skin of the right upper extremity. At the time of re-
application there is no data on recurrence of the disease. On examination, the postoperative scar
without features, the skin of the right upper limb in the forearm and elbow joint is swollen, pasty,
moderately hyperemic. The local temperature is slightly elevated compared to the other limb.
Question: What is the most probable complication of the patient?
What is the amount of medical care to correct the identified violations?
Answer: it is a complication of lymphedema or lymphostasis (lymphatic stagnation).
Lymphedema is one of the most complex pathologies that develops most often. It occurs due to a
violation of lymph flow and blockage in the lymphatic system on the operated side. Also, radiation
therapy is often complicated by fibrosis of muscles and lymphatic vessels. These disorders can
cause painful and potentially debilitating swelling in the arm and on the side where the operation
was performed. According to the study, lymphedema develops in approximately 30% of patients
who have undergone mastectomy. It can occur immediately or several months or even years after
surgery. A woman who has had many lymph nodes removed has an increased risk of developing
lifelong lymphedema. It is a chronic condition that requires constant monitoring, prevention and
treatment.
Limitation of the amplitude of movement in the shoulder joint. If adequate physical therapy is not
started in time in the postoperative period, the risk of inelastic, massive scar and violation of normal
motor function of the shoulder with the formation of contracture (reduction of the amplitude of
movements in the joint) increases.
Pain postmastectomy syndrome. As a secondary complication after surgical treatment of breast
cancer, chronic pain is possible. It has a neurological origin due to injury to nerves and soft tissues
in the operated area. Such pain can have different character, intensity, duration and be localized in
the front part of a thorax, axillary or in the middle part of a shoulder. For overcoming of this
problem usually appoint complex therapy: physiotherapy, medical treatment and means of
physical therapy. It has been scientifically proven that exercise is effective in overcoming
postoperative pain. Regular exercise helps maintain physical activity at a sufficient level, improves
overall health, improves sleep and the ability to control pain. Phantom pain. This is a common
feeling after a mastectomy, which can occur due to nerve healing. Manifested by itching, "creeping
ants" or general hypersensitivity in the operated area. Usually over time, these complaints go away
on their own and are not a medical problem. However, sometimes it is advisable to prescribe
nonsteroidal anti-inflammatory drugs, exercise or massage. Posture disorders. Weight removal may
result in weight asymmetry and functional muscle imbalance. To avoid deformity of the spine in the
thoracic region, pterygoid protrusion of the scapula, subsidence of the subclavian area, etc., it is
necessary to begin rehabilitation in time.
Task 65
A patient with small cell lung cancer 3 months after palliative chemotherapy developed swelling of
the face and neck, cyanosis of the skin of the face and neck, swelling of the veins of the neck and
upper extremities, a network of varicose veins on the anterior surface of the chest. At the same time
the patient complains of shortness of breath, cough, chest pain, hoarseness.
Question:
What is the most likely complication of the patient?
What is the amount of medical care to correct the identified violations?
Answer standard:
Syndrome of the superior vena cava as a result of its compression by metastatically affected
mediastinal lymph nodes.
Treatment of superior vena cava syndrome includes the use of special methods (radiation therapy,
chemotherapy - including regional, intraarterial) and general methods: the appointment of diuretics
(furosemide, verospirone), corticosteroids, cardiotropic therapy, oxyge.
Task1
A child of 3 years old played with small toys. Suddenly, a strong coughing fit began. Objectively:
consciousness is preserved, the face is cyanotic, the child coughs, breathing is loud, wheezing.
1. What happened to the child?
Foreign Body Obstruction
2. What conditions should be used for differential diagnosis?
Acute stenosing laryngotracheitis, whooping cough, allergic laryngeal edema, laryngospasm, tumors and
head injuries, asthma attack, acute obstructive bronchitis, acute epiglotitis.
3. What emergency measures need to be taken now?
In children 1-8 years of age:
1. Keep the baby on the thigh upside down, hit 5 times between the shoulder blades.
2. Turn the child on his back. Quickly press the sternum at the level of the interstellar line 5 times.
3. Inspect the oropharynx, try to remove the foreign body. After removal - mechanical ventilation.
4. If the measures are unsuccessful, repeat the entire cycle until the foreign body is removed.
5. If there is a loss of consciousness → conduct cardiopulmonary resuscitation.
6. Immediate transportation of the victim to a specialized hospital, removal of a foreign body from
using a bronchoscope.
4. Interpretation of the results of an additional examination.
Pulse oximetry (determination of blood oxygen saturation (normal - 95%).
In the diagnosis of foreign bodies of the bronchi, X-ray methods are of exceptional importance. Full
bronchostenosis gives atelectasis. Partial - reduced transparency of the corresponding part of the
lung. Valve
bronchostenosis leads to emphysema or part of it - depending on the location of the foreign body,
the mediastinum is shifted in the opposite direction and the opposite lung is dabbled. On the
the x-ray in this case, the lung, on the side of which there is a foreign bod y, looks more transparent,
than a healthy lung. This can lead to a diagnostic error: it is concluded that the foreign
the body is on a healthy side. With fluoroscopy in such patients, a typical mediastinal displacement by
inspiration towards bronchostenosis, that is, a foreign body (a positive symptom of Goltsknecht-
Jacobson). it
due to the fact that an excursion of a healthy lung is always more than in the lungs with a pathological
process.
Direct laryngoscopy, tracheoscopy, bronchoscopy are used to detect foreign bodies in
relevant departments of the respiratory tract.
Task 2
Firefighter 35 years old during a fire extinguishing received burns. Objectively: both upper limbs and
the front surface of the body is covered with a black scab, painless to the tou ch. Consciousness is clouded
reacts to loud calls. Pulse of 120 beats in hvilina.AT - 80/50 mm RT.
1. Formulate a clinical diagnosis.
Very severe burn burn. Torpid phase
2. What is the burn surface area?
36% of the body surface
3. What is the degree of burns you observe?
4 degree
Ht - 0.65-0.68, hemoglobin - 180-190 g / l, total protein - 52-50 g / l. Hyponatremia, hyperkalemia,
oligoanuria (amount of urine from 30 to 5 ml / h).
Task3
In the summer, an emergency occurred on the shore of the reservoir - one of the vacationers began to
sink. Rescuers managed to pull out
him out of the water after 3 minutes. On examination, the skin is pale, the pulse is not detected, breathing is
not
listens to.
Drowning, complicated by clinical death.
biological death
3. What is the sequence and correlation of emergency measures?
Pulling out of the water, free from water and foreign bodies of the oral cavity with a finger wrapped in
cloth,
return belly down, lay on the knee so that the head hangs down, press on the back and ribs. At
lack of vital signs - immediately begin cardiopulmonary resuscitation (CPR): compression
chest and artificial respiration in a ratio of 30: 2. The frequency of clicks should be 100-120 per
one minute, and you need to compress the chest by 5-6 cm. If available, use automatic
external defibrillator (AZD)
4. What are the features of the basic resuscitation complex of a drowned man?
The process of helping the drowned man is divided into four phases:
1. Rescue from the water (it is necessary to make sure of your own safety and assess the situation)
2. Basic life support (Features - for suspected cervical spine injury:
avoid displacement of the head relative to the body, support the head and neck of the victim on one
level with the dorsal, lay the victim on the board and fix it in her.
resuscitation - do not straighten the neck)
3. Extended life support. (Oxygen therapy is indicated for patients with a decrease in
saturation less than 95% (inhalation with moist oxygen should be carried out using a mask or through the
nasal
catheter at a speed of 3-5l / min.;
Drug therapy:
- the introduction of antihypoxants:
- Ascorbic acid 5% - 0.3 ml / 10 kg intravenously;
- the introduction of perfusion solutions:
- Hydroxyethyl starch - 500 ml intravenously;
- Dextrose (glucose) 5% - 400 ml intravenously;
- sodium bicarbonate 4% 200 ml intravenously;
- upon excitation:
- diazepam 0.5% - 2-4ml (then 2 ml intravenously until the effect is obtained)
- sodium oxybutyrate 20% - 10-20 ml intravenously in a 5% glucose solution.
- introduction of corticosteroids:
- Dexamethasone 0.4% - 12-20 mg;
- introduction of saluretics:
- furosemide 1% 20-40 mg intravenously.
4. postresuscitation treatment.
(In victims of drowning after extraction from water, an increased risk of developing acute
respiratory distress (SRH), which requires the use of protective ventilation strategies.)
Task4
During blood sampling from the finger, the patient turned pale, covered with a cold sweat, and lost
consciousness.
Objectively: a sharp pallor of the face, the reaction of the pupils to the light is preserved. Pulse - 82 beats. /
Min., HELL -120/75
mmHg
1. What condition did the victim develop?
Syncopal condition.
Convulsions, epilepsy, commas, collapse, TIA, shock.
3. What are the emergency care tactics?
- give a horizontal position to the body, raise legs by 25º;
- free neck and chest from tightening clothes
- provide access to fresh air;
- provide a reflex effect on the centers of respiration and cardiovascular regulation (inhalation
ammonia vapor spraying face with cold water)
- turn your head to the side (prevention of retraction of the tongue) with confidence in the absence of
damage
subclavian and carotid arteries.
In the absence of the effect of the measures taken and with a pronounced decrease in blood pressure:
• introduce sympathicotonic agents: 1% solution of mesatone, 5% solution of ephedrine hydrochloride
• in case of cardiac arrhythmias, prescribe antiarrhythmic drugs;
• in cases of bradycardia or cardiac arrest, administer a 0.1% solution of atropine sulfate, apply indirectly
heart massage.
When evaluating the results of an additional examination, pathological changes were not detected.
Task5
In a 30-year-old accident victim, a closed fracture of the middle third
the femur and numerous pelvic fractures.
1. How much blood loss is possible with this localization of lesions?
Fracture of the femur ≤1-1.5 L, pelvis ≤ 2-2.5 L (≈500 ml per 1 fracture site).
2. What methods of determining the amount of blood loss can be used on prehospital
stage?
• Assess skin color on exposed parts (brushes): blue, pink, pale or marble. Sizov Color
shells.
• Assess limb temperature cold or warm.
• Evaluate capillary filling - normally up to 2 sec., Increased capillary filling may
indicate decreased peripheral perfusion.
• Assess filling veins - may be moderately filled or feverish with hypovolemia.
• Determine heart rate. Find a peripheral pulse and a pulse on a large artery, evaluate its presence,
frequency,
quality, regularity and symmetry.
• Measure BP, BH.
• Listen to heart sounds.
• Pay attention to other symptoms that would indicate a decrease in cardiac output, such
as impaired consciousness, oliguria (urine volume <0.5ml / kg / h).
3. What are the emergency care tactics?
Anesthesia with narcotic or non-narcotic (nalbuphine) drugs, infusion therapy
crystalloids, position on the shield with a roller under the knee joints and abducted limbs,
immobilization of an unstable pelvic fracture with a pelvic girdle, belt or improvis ed means, and
immobilization of the thigh - three joints of the lower extremity (hip, knee, tibia). Enter in /
in solutions, and if, despite a rapid infusion, ≈1500-2000 ml of crystalloid solution (or ≈1000 ml
colloidal solution), hypotension and hypoperfusion persist → apply norepinephrine or dopamine
(or adrenaline) in a continuous intravenous infusion and at the same time continue the infusion of solutions.
Task6
You are an emergency doctor. During transportation, the patient, a man of 62 years, suddenly
turned pale and fainted. On examination: no consciousness, no breathing for 10 seconds, pulse
on the main arteries is not determined.
1. What urgent condition did the victim develop?
Clinical death.
Tela, shock, coma.
1. The patient with his head as far as possible is laid on a solid foundation.
2. You need to start resuscitation with a precardial stroke only at the very beginning
clinical death, in case of impossibility to carry out immediate defibrillation, (precardial stroke
is optional and can only be done by an experienced medical professional). Further -
Indirect cardiac massage. Restoring airway patency. Artificial ventilation
lung (mechanical ventilation) "mouth to mouth". Indirect cardiac massage is performed with a frequency of
at least 100 presses per minute in
ratio to artificial respiration 30: 2, press on the sternum above the xiphoid process. Bias
the sternum to the spine is carried out at 5 cm, while there can often be a fracture of the ribs. You can not
interrupt
heart massage for more than 10 seconds. It is better to use a device for artificial respiration (bag
AMBU).
Carry out electrical defibrillation with a discharge of 200, 300 and 360 J, respectively, using biphasic
defibrillator. If the VF is maintained, then after 2 minutes the application of the 360 J discharge is repeated.
single-phase defibrillator, the energy of the first discharge is 360 J. Classic layout
electrodes: the second intercostal space to the right of the sternum; left - at the location of the chest
electrode V4-V5.
Intubate the trachea and provide venous access.
4. What medications can be used?
1. In the case of asystole, intravenous adrenaline 1 mg (1 ml of a 0.1% solution of adrenaline
hydrochloride) every 3-
5 minutes. When circulatory arrest due to FS or VT occurs, adrenaline is prescribed after the third
ineffective discharge of electric defibrillation at a dose of 1 mg intravenously. If ECG persists
ventricular fibrillation, adrenaline is administered in the same dose with an interval of 3-5 minutes for the
entire period
CPR.
2. In the case of FS or VT, refractory to electro-pulse therapy (after the third ineffective discharge),
Amiodarone (cordarone) is prescribed in an initial dose of 300 mg (diluted in 20 ml of physiological
solution). If necessary, re-administered in a dose of 150 mg. After recovery hemodynamically
effective rhythm continues intravenous drip at a dose of 900 mg during the day.
3. Lidocaine - the initial dose is 100 mg, if necessary, 50 mg is additionally bolus administered
(total dose should not exceed 3 mg / kg per hour). In the absence of amiodarone, lidocaine can be used
as an alternative drug.
Lidocaine should not be used as a supplement to amiodarone.
The use of atropine during CPR is not recommended!
Cardiopulmonary resuscitation should last at least 30-40 minutes.
Task 7
A 69-year-old woman fell from a chair to her side on the floor. He cannot get up due to pain in the right hip
joint.
The lower limb is shortened and rotated outward. Victim can't raise straightened right
Lower limb. Palpation of the area of the right hip joint is painful.
Hip fracture
Fracture of the diaphysis of the femur, Prelo of the head of the femur, fracture of the pelvic bones,
3. What are the tactics of emergency medical care?
Place the victim on a flat surface, fixing the leg with a Dieterex tire
(immobilization of the ileum, knee joints), hospitalization.
introduction:
- Morphine hydrochloride Morphini hydrochloridum
(Under the skin, intramuscularly 1 ml of 1% solution; iv in 1 ml of 1% solution) or
- Promedol
(Under the skin, im 1 ml of a 2% solution) or
- naloxone hydrochloride Naloxoni hydrochloridum
(Under the skin, intramuscularly, into a vein 0.0004-0.008 g)
- In / in cap. Hekodes, NaCl 0.9%, rheosorbylact, lactasol - anti-shock.
When shown in thrombolysis, streptokinase, Actalysis, Hemase
Task8
Patient B., aged 30, was diagnosed with clinical death.
1. What signs are determined when deciding on the beginning of a basic resuscitation complex (BLS)?
1. Lack of pulse on the carotid arteries
2. Lack of breath ..
3. The expansion of the pupils in the absence of a reaction to light (develops after 30 seconds - 1 minute
from the moment
circulatory arrest).
II. Additional signs.
1. Lack of consciousness.
2. Pallor (earthy-gray color), cyanosis or marbling of the skin.
3. atony, areflexia.
2. What is the ratio of chest compressions to sighs?
30/2
3. Under what conditions is it possible to terminate the basic resuscitation complex?
1. Restore self-circulation - the appearance of a pulse on the main arteries
(chest compression stops) and / or breathing (stop ventilation)
2. Ineffectiveness of resuscitation for 30 minutes.
An exception are conditions in which it is necessary to prolong resuscitation: hypothermia
(hypothermia), drowning in ice water, overdose of drugs or drugs,
electric shock, lightning strike;
3. the onset of obvious signs of biological death: the maximu m expansion of the pupils with the appearance
of
called dry "herring shine" due to the drying of the cornea and the cessation of lacrimation;
the appearance of positional cyanosis, primarily - cyanotic coloration appears along the posterior margin of
the ear
shells and the back of the neck, back stiffness of the muscles of the limbs, does not reach the degree of
cadaveric
rigor.
4. When is it possible not to perform mouth-to-mouth artificial respiration?
1. In the presence of obvious interference with the movement of air through the respiratory tract (swelling
of the larynx in the victim,
foreign body of the respiratory tract, acute, ongoing bleeding, manifested by blood secretion
through the mouth)
2. In the absence of personal protective equipment.
Task9
Injured P., 36 years old, received a penetrating wound in the left half of the chest. Objectively: state
moderate severity, half-sitting position, pale skin, pronounced cyanosis of the lips and hands. Breath
frequent, difficult. During breathing, air is absorbed into the wound. Pulse 100 beats per minute,
satisfactory performance. HELL - 110/70 mm Hg
Post-traumatic valvular (intense) pneumothorax on the left
Atelectasis of the lungs, rupture of the main bronchus, closed / open pneumothorax
Valvular pneumothorax translate into open.
Urgently insert a catheter into the pleural cavity through the II intercostal space in the midclavicular line
(along the upper edge of the III rib) using a catheter (identical as for peripheral veins) 4-5 cm long
and with a diameter of 2.0 mm (14 G) or 1.7 mm (16 G) and leave it until the drain is inserted.
The department has passive drainage and further surgical treatment.
- Introduction to / in cap. Hekodes, NaCl 0.9%, rheosorbylact, lactasol.
Task 10
As a result of an accident, a 54-year-old woman was injured by shattered glass. The condition is
serious. The skin is pale. On the face
drops of sweat. Thirst. Pulse 120 beats per minute, weak. AO - 90/60 mm Hg In the middle third of the left
shoulder
bleeding wound, blood flows slowly, dark in color. Pathological mobility in the field
there is no left shoulder.
Damage v. cephalica or v. basilic
Arterial bleeding
Temporary methods to stop bleeding: tight wound tampon ade, maximum limb flexion
joint, applying a pressure bandage, applying Jug below the wound.
Introduction in / in cap. Hekodes, NaCl 0.9%, rheosorbylact, lactasol.
Hospitalization in the surgical department.
Task 11
A 40-year-old man who suffered a car accident was diagnosed with a closed comminuted fracture.
hip diaphysis, concussion, multiple rib fractures, scalp wound
lower legs.
traumatic shock
2. Which of the lesions should be considered dominant?
Closed comminuted femoral diaphysis fracture
1) Put the patient on a flat surface.
2) Assess the patency of the diachal paths, the work of the CCC.
3) Anesthesia by injection of narcotic or non-narcotic
analgesics (2 ml of 50% analgin, diphenhydramine 1% - 2.0 ml, morphine hydrochloride - under the skin,
intramuscularly 1
ml of 1% solution; in / in 1 ml of 1% solution) or Promedol (under the skin, in / m 1 ml of 2% solution) or
naloxone
hydrochloride (under the skin, intramuscularly, into a vein 0.0004-0.008 g)
- intramuscular injection of 4 ml of cordiamine
- intramuscular injection of 1 ml of 20% caffeine
- 400 ml of plasma substitutes (sorbylact, rheos orbylact, reopoliglyukin) or 400 ml
Ringer's solution or saline.
4) Aseptic dressing for open wounds.
5) immobilization of fractures with improvised means or transport
immobilization by personnel means.
7) Urgent hospitalization
Closed heart massage is performed if the patient has asystole or weakness of the heart;
4. Interpretation of the results of an additional examination
Task 12
A 42-year-old man has complaints of general malaise, headache, dizziness, and a sensation of heat. At
the survey revealed that the victim from 10 to 16 hours sunbathing on the beach. On examination: skin
hyperemic, body temperature 37.8 ° C, respiration 18 per minute, pulse - 110
beats / min., weak onsite, breathing is frequent.
1. Establish a preliminary diagnosis.
Solar - heat stroke
2. Identify emergency care tactics.
1.Romistitis of the victim in a cool place.
2. Give him chilled water (18 ° C), give strong iced tea or cold salted water (1/2
teaspoon of salt per 0.5 l of water);
3.Rebut the victim's clothes, remove the compressive clothes;
4.Vologians place cool compresses on the site of large vessels (lateral surface of the neck,
axillary site) and on the forehead;
5.Zagalen cooling.
6. If the condition worsens - infusion therapy.
3. What drugs are used to treat?
Intravenous bolus drip of isotonic sodium chloride solution (room temperature) - 20 ml
/ kg body weight.
4. Interpretation of laboratory examination results
Task 13
Woman, 73 years old, burns in household gas cylinder
head, neck, and two upper limbs.
1. What is the area of the burn?
For this purpose, use the rule of nines, according to which the area
- head and neck equal to 9%,
- any upper limb - 9% each
- front and back surface of the body - 18% each,
- each lower limb - 18% (9% lower leg 9% thigh)
- perineum - 1%
So the burn - 27%
2. What is the Frank index (rule hundreds)?
Predictive Index.
The rule "hundreds" - the age of the patient + burn area in%
(Up to 60 - the forecast is favorable; 61-80 - the forecast is relatively favorable; 81 - 100 - the forecast
doubtful; 101 and more - the forecast is unfavorable).
In this case, the forecast is dubious
3. What is the Parkland formula?
formula
V = 4 * m * (A * 100)
where: m - body weight in kg A - burn surface area, 4 - coefficient. recounting.
The formula for calculating the volume of infusion fluid necessary for the patient during
first 24 hours.
The first half is introduced in the first 8 hours after the injury, the next part in the next 16 hours.
Coef. 4 for children over 3 years old and adults, 4.5 for children from 1 to 3 years old and 5 for children
under one year old.
4. What is the tactics of emergency medical care?
1. Remove hot, charred clothes or clothing smoldering, or cramped objects on your body, but do not touch
that stuck to the skin.
Cool the affected area with cold water for at least 20 minutes. Cooling can be effective in
during the first three hours after the defeat. Areas that are not affected should be left dry and
warm. Stop cooling if body temperature drops to 35 ° C.
2. Stabilize the neck due to possible injury to the cervical spine.
Inspect the airways for foreign material or swelling. If the patient cannot respond
on oral commands, open the airways by lifting the chin and sliding
forward the lower jaw.
- Minimize the movement of the cervical spine and avoid excessive bending
or extension of the head or neck.
- Enter the oropharyngeal duct in case of impaired respiratory
ways. Consider early intubation.
3. Ensuring the patient's breathing.
4. Control of BH, pulse, heart rate.
5. Review for bleeding.
6. Definition of consciousness of the victim.
7. Catheterization of peripheral veins and the bladder.
8. Anesthesia in / in narcotic drugs with a slight increase in dose. standard
the dose of iv morphine is 2.5-10 mg for adults
9. Introduction Reftan, physiological saline, glucose 5%, r-albumin, rn fresh frozen
plasma. Introduction trental, latren, soda buffer.
10. Applying an aseptic dressing to the burn sites - emergency hospitalization.
Task14
The victim B. is 30 years old with external bleeding, blood pressure is -100/60 mm. Hg. Art., pulse -
100.
1. Determine the approximate amount of blood loss using the Algover index100 / 100 = 1
The Algover index indicates the stage of shock in humans, is determined by the formula PS / ATsystolic.
Algover index is 0.5.
with an index equal to 1 (for example, PS / ADS = 100/100), the volume of blood loss is 20% of the bcc,
which
corresponds to 1 - 1.2 liters in an adult;
- with an index of 1.5 (for example, PS / ADS = 120/80), the volume of blood loss is 20% - 40% of the bcc,
which
corresponds to 1.5 - 2 liters in an adult;
- with an index equal to 2 (for example, PS / ADS = 120/60), the volume of blood loss is more than 40% of
the bcc, that is
more than 2.5 liters of blood.
2. What is an empirical definition of blood loss?
Empirical methods for estimating blood loss are most often used for injuries and polytrauma. AT
they use the average statistical values of blood loss established for a particular species
damage. You can also tentatively estimate blood loss in various surgical
interventions.
Average blood loss (L)
1. Hemothorax - 1.5-2.0
2. Fracture of one rib - 0.2-0.3
3. Belly injury - up to 2.0
4. Fracture of the pelvic bones (retroperitoneal hematoma) - 2.0-4.0
5. Hip fracture - 1.0-1.5
6. Fracture of the shoulder / lower leg - 0.5-1.0
7. Fracture of the bones of the forearm - 0.2-0.5
8. Fractures of the spine - 0.5-1.5
9. Palm-sized scalp wound - 0.5
Operating blood loss
1. Laparotomy - 0.5-1.0
2. Thoracotomy - 0.7-1.0
3. Shin amputation - 0.7-1.0
4. Osteosynthesis of large bones - 0.5-1.0
5. Resection of the stomach - 0.4-0.8
6. Gastrectomy - 0.8-1.4
7. Resection of the colon - 0.8-1.5
8. Caesarean section - 0.5-0.6
3. From which solutions do you need to start restoring the volume of circulating blood?
As for the structure of the use of infusion media in the restoration of BCC, in Western countries
In Europe, the use of gelatin preparations accounts for 26%, hydroxyethyl starch derivatives - 21%, and
dextran leaf 1%. In Ukraine, the structure of the use of infusion media is completely different: preference
among
colloids, as before, have dextran, to some extent a derivative of hydroxyethyl starch and
only to a small extent - gelatin preparations.
Crystalloid solutions. Crystalloid solutions, when introduced into the vascular bed, cause
the volemic effect of the first 15-30 minutes, and then move into the interstitial tissue, and causes them
short-term volemic effect. With bleeding, the use of Isoosmolar is indicated
polyionic electrolytes with backup alkalinity carriers (Ringer-lactate, Lactasol, etc.).
The use of large volumes of crystalloid solutions is not justified in most cases,
since it can lead to pulmonary edema in patients with cardiac pathology. To an extent
the disadvantages of massive infusions of isotonic crystalloid solutions can be avoided by
hypertonic solution of sodium chloride (7.5%), which is administered in a limited dose to 4 ml / kg TO
The adverse effects of such infusions include the fact that they can cause cellular dehydration and
arrhythmias.
Colloidal solutions. Large molecules of colloids normally do not penetrate the vascular endothelium.
Therefore, they restore BCC more efficiently, circulate much longer in the vascular bed than
crystalloids and contribute to improved perfusion and increased oxygen delivery to tissues.
Dextrans. As shown by 60 years of experience using dextrans, these drugs have much more
negative effects than positive. Along with the benefits, these drugs have a number of significant
disadvantages, one of the main of which is a negative effect on the hemostatic system. This is due to their
restrictions in the complex infusion therapy of blood loss. Of the dextran preparations, there may be
only a limited dose of Reopoliglukin was used, mainly to improve the rheological properties
blood.
Solutions of hydroxyethylated starch (HES). First generation HES solutions, as well as dextrans,
negatively affecting the hemostatic system. This is due to the fact that HES molecules due to the "silicone"
the effect of reducing platelet adhesion and aggregation, reduces the activity of factors VIII and IX,
antithrombin
III and fibrinogen. The well-known Reformed, Stabizol, Volek and others belong to the first generation
HES.
Second generation HES solutions can reduce capillary permeability and tissue edema. In conditions
ischemic-reperfusion injury HES solutions reduce the degree of damage to the lungs and internal
organs, reduce the frequency of pulmonary edema compared with the use of albumin so lutions and
isotonic sodium chloride solution. Of the HES preparations, Infucol HES 6% can be used,
Infucol HES 10%, HAES 6%, HAES 10% with a molecular weight of 200,000 D.
Gelatin preparations. From this group, only a modified liquid preparation can be us ed.
Gelatins - Gelofusin 4% (Germany). The hemodynamic effect of gelofusin is close to HES. Even in large
doses it does not affect hemostasis.
Polyethylene glycol preparations. Well established in clinical use
polyethylene glycol-based blood substitute - Polyoxidine.
Albumin solutions. Recent studies have shown that with hemorrhagic shock, 5% albumin,
due to impaired capillary permeability, quickly penetrates into the interstitial space and
may contribute to the deepening of interstitial edema and the development of pulmonary edema. Therefore,
it is believed that
5% albumin can be used to lower total blood protein below 50 g / l or albumin below 25
g / l, CAT - below 15 mm Hg. Art. Moreover, the rate of administration of albumin should not exceed 1-5
ml / min.
BSC. The main indication for the inclusion of FFP in IVS is to fill the deficit of coagulation factors and
correction of disseminated intravascular congestion syndrome.
Red blood cells.
4. What methods of stopping external bleeding do you know?
Capillary bleeding, when blood oozes from damaged vessels, stops
applying a pressure bandage.
Venous bleeding when a stream of dark red blood flows continuously from a wound. Stop him
by giving an elevated position to the damaged part of the body and by ap plying a tight pressure bandage.
If large veins are damaged, bleeding is stopped by applying a tourniquet above the site of injury.
Arterial bleeding when scarlet blood flows from the wound. Stop her with a finger clip
arteries to the adjacent bone by applying a pressure bandage, tourniquet or twist. Bleeding from small
arteries can be stopped by applying a pressure bandage: several layers are applied to the wound
sterile gauze or bandage, then a layer of cotton wool, and all this is tightly bandaged.
overlay bleeding above the juta bleeding site. Lito-120 min, Winter -60 min. Stop
bleeding from wounds of the extremities by their flexion in the joints with subsequent fixation is the second
in a reliable way. In the area of articular flexion, a roller of gauze or cotton wool is pre-placed.
Task15
Injured G. 45 years old, received on the surface superficial burns of the head, neck and lower left
limbs.
- perineum - 1%. So = 9% + 9% = 18%
2. What is the Frank index (rule hundreds)?
The prognosis and outcome of a burn disease, depending on the prognostic index, can be determined by
The "rule of the hundreds" and the Frank index.
Rule hundreds This prognostic index is determined by the sum of the indicators of age and area of the burn.
Forecast for the Frank index When calculated, it is assumed that 1% of the burn is equivalent to: for burns
of the 1st, 2nd century.
= 1 unit, burns IIIa = 2 units and for burns IIIB, IV degree = 3 units. With a burn of the upper
respiratory tract to the obtained Frank index should add another 20 units.
3. At what area of superficial burns in adults should shock be expected?
With superficial burns of more than 20-30% and deep burns of more than 10% of the body surface (in
children 5%)
pronounced general disorders of the whole organism develop - burn shock. Plasma loss up to 20-30% of
BCC.
The depth and area of the burn affect the development of this condition. Adverse factors include
concomitant diseases, childhood and old age of the affected, concomitant upper burns
respiratory tract, eyes, genitals.
4. What is the Parkland formula?
formula for calculating the volume of infusion therapy
Parkland’s formula 3-4 ml x kg x% burn - protrusions 24 hours.
The calculation is carried out according to the following scheme: 100 ml x kg - for the first 10 kg of weight
+ 50 ml x kg for each kg from 11-20 kg + 20
ml x kg for the next after 20 kg of body weight.
Thus, a child weighing 23 kg needs 1000 ml + 500 ml + 60 ml = 1560 ml / 24 hours. This liquid may
be administered enterally.
The adequacy of infusion therapy is assessed based on hemodynamic data (heart rate, blood pressure, CVP)
and
hourly urine output .. In the first 8:00 half of the estimated volume (glucose-salt solutions in
1: 1 ratio). In the next 8:00, 5% glucose is replaced by 10%. 16-24 hours are appointed native
colloids albumin SSP.
Task 16
G., who suffered 3 years, received superficial burns to the head and neck in everyday life.
- perineum - 1%. So = 9%
2. At what area of superficial burns in children should shock be expected?
With superficial burns of more than 20-30% and deep burns of more than 10% of the body surface (in
children 5%)
pronounced general disorders of the whole organism develop - burn shock. Plasma loss up to 20-30% of
BCC.
The depth and area of the burn affect the development of this condition. Adverse factors include
concomitant diseases, childhood and old age of the affected, concomitant upper burns
respiratory tract, eyes, genitals.
3. What is the palm rule?
The palm area of an adult is approximately 1% of the total surface of the body. Therefore the area
burns can be determined by the conditional number of palms that can cover the damaged
surface. Each palm + 1%.
4. What are superficial and deep burns?
The skin consists of two layers: epithelial tissue - the epidermis and connective tissue - the
dermis. Epidermis
constantly updated due to the growth of new epithelial cells - basal and spike. In the layer
basal cells contain the surface endings of blood vessels providing
blood collection of the skin. In the case of death of cells of the germ layer, the growth of the epithelium in
the affected area is not
occurs and the defect is closed by secondary intention with the help of connective tissue - scar. AT
depending on whether the affected germ layer or not, that is, whether there is further epithelization or not,
distinguish between superficial and deep burns. Burns of I, II, III-A degrees are superficial, cutaneous
the cover after them regenerates independently. Burns of III-B and IV degrees - deep, if they are
occurrence carry out surgical correction.
Task17
On a slippery road, the bus driver lost control and the bus rolled over. C 42
16 passengers received mechanical damage of varying severity.
1.How is medical sorting done?
- This is the process of determining the priority of patient care depending on the complexity of their
condition.
• identify the patient.
• testify to the findings of the assessment.
• identify the priority of the patient's need for medical care and transportation from the place
emergency incident.
• Track patient progress through the medical grading process.
• identify additional hazards such as pollution.
The first stage of medical sorting is carried out at the emergency site, but at
a safe distance from the action of its damaging factors. At this stage of medical sorting
there is the first contact of the medical worker who conducts medical sorting, with
affected.
1.1. During the first stage of medical sorting, a certain such basic volume
medical care in adults check for breathing and, if necessary, restore
airway determine the capillary pulse determine the state of consciousness in children up to
8 years to restore airway patency in the absence of breathing perform 5
artificial breaths.
1.2. The duration of the first stage of medical sorting is no more than 60 seconds.
At the first stage of medical sorting, medical personnel designate the victim as sorting
a bracelet.
2. The second stage of medical sorting is carried out on an urgently prepared sorting site, in
the time of transportation of the victim to the health care institution, in the reception departments. .
The basic scope of the medical examination: definition: blood pressure pulse on the central and
peripheral arteries; respiratory rate, capillary pulse, monitoring of vital signs;
blood saturation.
At the second stage of medical sorting, an accounting statistic is filled in for each victim
medical documentation form No. 109-2 / о “Medical sorting card” (hereinafter - the card)
medical sorting).
2. What sorting groups for medical grounds exist?
Category
(corresponding
Colour)
The state of health of the victim
Medical
activity
And (red)
Threatened by life. Immediate threat to life
which can be eliminated provided immediate
medical assistance, evacuation and
subsequent treatment
Immediate
medical care.
Hospitalization in
first of all
AI (yellow)
Severely injured or sick. The condition of the victim
of stable vital indicators,
Medical
help and
allowing you to expect and get medical
help secondarily
hospitalization during
second stage
III (green)
Slightly injured or sick. Insignificant
satisfactory health damage
general condition of the victim with the possibility
waiting for medical care is long
term
Assisting in
third turn with
subsequent
(outpatient)
treatment
IV (dark
Violet /
the black)
There is no chance of life. Health damage
injured who are incompatible with life
Care. Palliative
medical care with
possible evacuation in
medical institution
dead body
Identification.
death statement
Sorting categories of victims are determined according to the following criteria:
Sorting
category
(matching color)
Consciousness (by
scale com
Glasgow)
Breath
(frequency
breathing)
circulation
1
2
3
4
I (red)
10 and less
points
Less than 10 or
more than 30 in 1
min
Capillary pulse for more than 2 seconds.
No peripheral pulse
II (yellow)
14 - 11 points Not less than 8 and not
more than 30 in 1
min
Capillary pulse less than 2 seconds.
Pulse in the peripheral arteries
is present
III (green)
Consciousness without
violations
Breathing without
violations
Blood circulation without disturbance
IV (dark purple /
the black)
consciousness
missing
consciousness
missing
consciousness is absent
breath
missing
Pulse on the main arteries
missing
3. What sorting groups exist for evacuation grounds?
There are five color sorting bracelets:
red - for victims of the first sorting category;
yellow - for victims of the second sorting category;
green - for victims of the third sorting category;
dark purple - for victims of the fourth sorting category;
black - for victims of the fourth sorting category.
Medical sorting divides the wounded into four groups:
• Hopeless - those who are out of relief
• Wounded, which can be helped by immediate transportation
• Wounded, whose transportation may be delayed
• Those who have minor injuries, who need help not so urgently
Medical sorting also sets evacuation and transportation priorities as follows
way:
• The dead remain where they fell. These people do not breathe, and the attempt to open the airways to
them was
unsuccessful.
• Urgent or priority 1 (red), evacuated by medical evacuation, if possible, or emergency
assistance, if necessary, in additional medical care once, or within 1:00. These
people are in critical condition and will die without immediate help.
• Delayed, or priority 2 (yellow) may not receive medical evacuation until
transported all immediate people. The condition of these people is stable, but requires
medical care.
• Minor, or priority 3 (green) are not evacuated until all immediate and
deferred person. These do not need additional medical care for at least
few hours. Continue sorting them again if their condition worsens. These people are capable
walk, and may require only bandages and antiseptics.
2. Adults who belong to the red sorting category, medical care and evacuation in
health care facility provided first. In the case when the transportation time
a victim in a multidisciplinary hospital can lead to a deterioration in his general state of health,
hospitalization is carried out in the nearest healthcare institution, has a sufficient resource for
providing the necessary amount of medical care or stabilizing the state of health
victim and preparation before transfer to the specialized hospital.
3. Adults who belong to the yellow sorting category receive medical care in
in accordance with certain of these General requirements for volume and evacuation is carried out after
affected red sorting category. Hospitalization is carried out in a health facility,
having sufficient resources to provide the necessary amount of medical care.
4. Adults who belong to the green sorting category receive medical care in
third turn. If necessary, hospitalization is carried out in health facilities.
5. Victims who received bodily harm, incompatible with life, but have signs
life, affect the sorting bracelets of dark purple and belong to dark purple /
black sorting category. They are given palliative care (care). Evacuation
carried out secondarily during hospitalization of victims of the red sorting category.
6. The bodies of the dead affect sorting bracelets in black, belong to dark purple /
black sorting category and sent to morgues or pathological bureau / bureau forensic
medical examination if there are enough vehicles and no
the need for evacuation of victims of other sorting categories.
7. In case of suspected presence of a dangerous infectious disease among the victims, medical
sorting is carried out with the implementation of anti-epidemic measures.
8. In case of contamination of victims with biological, chemical agents or radiation
factors decontamination of the contaminated surface of the clothes (body) of the victim
special units whose employees wear appropriate protective clothing.
Referral of victims to the marshalling yard for medical sorting is carried out after
decontamination of victims.
4. What categories of victims can be dangerous for you?
Who have a mental disorder, acute stress disorder or psychotrauma, objects that
weapons, knives may be in danger. a condition in which a person can harm himself, a condition in
which person can harm others.
Task 18
On a slippery road, the bus driver lost control and the bus rolled over. 15 passengers
received mechanical damage of varying severity.
1. How is medical sorting done?
- This is the process of determining the priority of patient care depending on the complexity of their
condition.
• identify the patient.
• testify to the findings of the assessment.
• identify the priority of the patient's need for medical care and transportation from the place
emergency incident.
• Track patient progress through the medical grading process.
• identify additional hazards such as pollution.
The first stage of medical sorting is carried out at the emergency site, but at
a safe distance from the action of its damaging factors. At this stage of medical sorting
there is the first contact of the medical worker who conducts medical sorting, with
affected.
1.1. During the first stage of medical sorting, a certain such basic volu me
medical care in adults check for breathing and, if necessary, restore
airway determine the capillary pulse determine the state of consciousness in children up to
8 years to restore airway patency in the absence of breathing perform 5
artificial breaths.
1.2. The duration of the first stage of medical sorting is no more than 60 seconds.
At the first stage of medical sorting, medical personnel designate the victim as sorting
a bracelet.
2. The second stage of medical sorting is carried out on an urgently p repared sorting site, in
the time of transportation of the victim to the health care institution, in the reception departments. .
The basic scope of the medical examination: definition: blood pressure pulse on the central and
peripheral arteries; respiratory rate, capillary pulse, monitoring of vital signs;
blood saturation.
At the second stage of medical sorting, an accounting statistic is filled in for each victim
medical documentation form No. 109-2 / о “Medical sorting card” (hereinafter - the card)
medical sorting).
2. What sorting groups for medical grounds exist?
Category (appropriate color) Health status of the injured person Medical measures
And (red) Life threatened. Immediate threat to life, which can be eliminated if
immediate medical attention, evacuation and subsequent treatment
immediate medical attention. Hospitalization first
AI (yellow) Severely injured or sick. The condition of the victim of stable vital signs,
allowing to expect and receive medical care secondarily
and hospitalization secondarily
III (green) Slightly injured or sick. Minor health damage with satisfactory overall
the state of the victim with the possibility of waiting for medical assistance for a long time
assistance in the third place with subsequent (outpatient) treatment
IV (dark purple / black) There is no chance of life. Injury injuries, incompatible
With Life Care. Palliative care with possible evacuation to a medical institution
Corpse Identification. death statement
Sorting categories of victims are determined according to the following criteria:
Sorting
category
(matching color)
Consciousness (by
scale com
Glasgow)
Breath
(frequency
breathing)
circulation
1
2
3
4
I (red)
10 and less
points
Less than 10 or
more than 30 in 1
min
Capillary pulse for more than 2 seconds.
No peripheral pulse
II (yellow)
14 - 11 points Not less than 8 and not
more than 30 in 1
min
Capillary pulse less than 2 seconds.
Pulse in the peripheral arteries
is present
III (green)
Consciousness without
violations
Breathing without
violations
Blood circulation without disturbance
IV (dark purple /
the black)
consciousness
missing
consciousness
missing
consciousness is absent
breath
missing
Pulse on the main arteries
missing
3. What sorting groups exist for evacuation grounds?
There are five color sorting bracelets:
red - for victims of the first sorting category;
yellow - for victims of the second sorting category;
green - for victims of the third sorting category;
dark purple - for victims of the fourth sorting category;
black - for victims of the fourth sorting category.
Medical sorting divides the wounded into four groups:
• Hopeless - those who are out of relief
• Wounded, which can be helped by immediate transportation
• Wounded, whose transportation may be delayed
• Those who have minor injuries, who need help not so urgently
Medical sorting also sets evacuation and transportation priorities as follows
way:
• The dead remain where they fell. These people do not breathe, and the attempt to open the airways to
them was
unsuccessful.
• Urgent or priority 1 (red), evacuated by medical evacuation, if possible, or emergency
assistance, if necessary, in additional medical care once, or within 1:00. These
people are in critical condition and will die without immediate help.
• Delayed, or priority 2 (yellow) may not receive medical evacuation until
transported all immediate people. The condition of these people is stable, but requires
medical care.
• Minor, or priority 3 (green) are not evacuated until all immediate and
deferred person. These do not need additional medical care for at least
few hours. Continue sorting them again if their condition worsens. These people are capable
walk, and may require only bandages and antiseptics.
2. Adults who belong to the red sorting category, medical care and evacuation in
health care facility provided first. In the case when the transportation time
a victim in a multidisciplinary hospital can lead to a deterioration in his general state of health,
hospitalization is carried out in the nearest healthcare institu tion, has a sufficient resource for
providing the necessary amount of medical care or stabilizing the state of health
victim and preparation before transfer to the specialized hospital.
3. Adults who belong to the yellow sorting category receive medical care in
in accordance with certain of these General requirements for volume and evacuation is carried out after
affected red sorting category. Hospitalization is carried out in a health facility,
having sufficient resources to provide the necessary amount of medical care.
4. Adults who belong to the green sorting category receive medical care in
third turn. If necessary, hospitalization is carried out in health facilities.
5. Victims who received bodily harm, incompatible with life, but have signs
life, affect the sorting bracelets of dark purple and belong to dark purple /
black sorting category. They are given palliative care (care). Evacuation
carried out secondarily during hospitalization of victims of the red sorting category.
6. The bodies of the dead affect sorting bracelets in black, belong to dark purple /
black sorting category and sent to morgues or pathological bureau / bureau forensic
medical examination if there are enough vehicles and no
the need for evacuation of victims of other sorting categories.
7. In case of suspected presence of a dangerous infectious disease among the victims, medical
sorting is carried out with the implementation of anti-epidemic measures.
8. In case of contamination of victims with biological, chemical agents or radiation
factors decontamination of the contaminated surface of the clothes (body) of the victim
special units whose employees wear appropriate protective clothing.
Referral of victims to the marshalling yard for medical sorting is carried out after
decontamination of victims.
4. What are the types of evacuation?
1) required;
2) general or partial;
3) temporary or irrevocable.
3. The decision to carry out the evacuation is taken:
1) at the state level - the Cabinet of Ministers of Ukraine;
2) at the regional level - the Council of Ministers of the Autonomous Republic of Crimea, regional, Kiev
and
Sevastopol city state administrations;
3) at the local level - district, district in the cities of Kiev or Sevastopol state
administrations, local governments;
4) at the facility level - heads of business entities.
4. In the event of radiation accidents, the decision to evacuate the population, which may fall into
radioactive contamination zone, accepted by local state administrations on the basis of
conclusions of the sanitary and epidemiological service in accordance with the projected dose load on
population or according to information of business entities that operate nuclear installations, about
cases of violations in their work.
5. In urgent cases, the head of the emergency response, and in case of
his absence - the head of the emergency services, was the first to arrive in the emergency zone,
may decide to carry out emergency evacuation of the population from the emergency zone or
areas of possible damage.
6. Compulsory evacuation of the population is carried out in the event of a threat:
1) accidents with the release of radioactive and hazardous chemicals;
2) catastrophic flooding of the area;
3) massive forest and peat fires, earthquakes, landslides, other geo logical and
hydrogeological phenomena and processes;
4) armed conflicts (from areas of potential hostilities to safe areas that
determined by the Ministry of Defense of Ukraine for a special period).
7. General evacuation is carried out for all categories of the population from zones:
1) possible radioactive and chemical pollution;
2) a catastrophic flooding of the area with a four-hour run-through of a breakthrough wave during
destruction
hydraulic structures.
8. Partial evacuation is carried out for the export of categories of the population that are by age or condition
health in the event of an emergency are not able to independently take measures to
the preservation of their life or health, as well as of persons who, according to the law, care
(serve) such people. Partial evacuation may also be carried out for other categories of the population.
by decision of the bodies and officials referred to in part four of this article.
Task19
Victim B., 30 years old, has external bleeding from a wound in the inguinal region. The bleeding is
moderate.
Blood is dark red. Blood pressure - 100/60 mm. Hg. Art., pulse - 100.
1. What symptom is determined at the prehospital stage in order to assess blood loss?
1. Local symptoms (external or internal bleeding)
2. General symptoms of bleeding (pallor of the skin of the body, impaired consciousness, blood pressure,
CVP; heart rate;
hourly diuresis, body temperature indicators of hemoglobin and hematocrit; tension of oxygen in the blood.
3. Special diagnostic methods (diagnostic puncture; endoscopy; laparocentesis, laparoscopy;
thoracocentesis, thoracoscopy; ultrasound angiography; radiography computer topography, myr.)
1. According to the location of the injury and the volume of damaged tissue.
2. By hemodynamic parameters ("shock index", systolic blood pressure).
3. According to the concentration indicators of blood (hematocrit, hemoglobin).
4. According to the change in the BCC.
When assisting the victim, you can tentatively determine the amount of blood loss by
localization of the injury: with severe chest injury, it is 1.5-2.5 liters, the abdomen - up to 2 liters, with
multiple pelvic fractures - 2.5-3.5 liters, open hip fracture - 1.5-1.8 liters, closed fracture
hips - 2 l, tibia - up to 0.8 l, shoulder - 0.6 l, forearm - 0.5 l.
An injured tissue volume indicator can be used and oriented by taking the wounded palm
per unit, which corresponds to approximately 0.5 liter blood loss. In this regard, all injuries are divided into
4 groups: 1.
Small wounds - the surface of the lesion is smaller than the surface of the palm. Blood loss is 10% of the
BCC. 2.
Medium-sized wounds - the damage surface does not exceed the area of 2 palms. Blood loss up to 30%
Bcc. 3. Large wounds - the surface is larger than the area of 3 palms, but does not exceed the area of 5
palms.
The average blood loss is about 40% of the BCC. 4. Wounds of very large sizes - the surface is larger than
the area 5
palms. Blood loss is about 50% of BCC.
2. What is an effective way to stop bleeding from wounds in adjacent areas?
Capillary bleeding, when blood oozes from damaged vessels, stops
applying a pressure bandage.
Venous bleeding when a stream of dark red blood flows continuously from a wound. Stop him
by giving an elevated position to the damaged part of the body and by applying a tight pressure bandage.
If large veins are damaged, bleeding is stopped by applying a tourniquet above the site of injury.
Arterial bleeding when scarlet blood flows from the wound. Stop her with a finger clip
arteries to the adjacent bone by applying a pressure bandage, tourniquet or twist. Bleeding from small
arteries can be stopped by applying a pressure bandage: several layers are applied to the wound
sterile gauze or bandage, then a layer of cotton wool, and all this is tightly bandaged.
overlay bleeding above the juta bleeding site. Lito-120 min, Winter -60 min. Stop
bleeding from wounds of the extremities by their flexion in the joints with subsequent fixation is the second
in a reliable way. In the area of articular flexion, a roller of gauze or cotton wool is pre-placed.
3. What is an alternative intravenous route for the administration of crystalloid solutions?
enteral method, if a person in consciousness, independently uses a number of, if unconscious, then through
probe as needed.
4. Determine the approximate amount of blood loss using the Algover index100 / 100 = 1
The Algover index indicates the stage of shock in humans, is determined by the formula PS / ATsystolic.
Algover index is 0.5.
with an index equal to 1 (for example, PS / ADS = 100/100), the volume of blood loss is 20% of the bcc,
which
corresponds to 1 - 1.2 liters in an adult;
- with an index of 1.5 (for example, PS / ADS = 120/80), the volume of blood loss is 20% - 40% of the bcc,
which
corresponds to 1.5 - 2 liters in an adult;
- with an index equal to 2 (for example, PS / ADS = 120/60), the volume of blood loss is more than 40% of
the bcc, that is
more than 2.5 liters of blood.
Task20
While in the mall, you saw a woman who was very handsome. On examination: skin
pale, no consciousness, breathing - 3 for 10 seconds.
1. Technique of the initial examination of the victim. Which meta-first review?
the purpose of providing adequate assistance is the confidence of the savior that the victim do es not
represent
threats to yourself and others.
If the victim has any change in mental state or manifestation of an inadequate
behavior before the examination and assistance should be disarmed and make sure that he does not have
items that may pose a threat (if this has not been done before). Also the savior is worth
Pay attention to objects that may be explosive. However, it should be estimated - the place
events, in particular, the presence of threats to the savior; - position of the victim; - nature of damage; -
the presence / absence of critical bleeding in the victim. You need to approach the face from the side of the
head,
mindful of personal safety. A gun in a policeman should be out of reach of the injured.
The main principle of the rescuer’s actions is that the safety of the savior is more important than the safety
of the victim.
Initial examination of the injured Savior must first of all verify the injured in consciousness and
he reacts to words (whether they are aware or not). This can be done by staging such simple
questions: “What happened to you?”, “Do you need help?”. 14 Approaching closer to the victim, should
ask again loudly, everything is fine with him, evaluating how he reacts to a harsh voice. Also
It is recommended that you shake the person slightly on the shoulder or tap your hand on the floor, as the
savior may
run into the deaf. It should also be borne in mind that explosions near the face can provoke a person
aggressive reaction, so the savior should take care of his own safety in advance. At
in the absence of reaction to the voice, the savior should choose a position that is convenient for care
(standing on one knee
on the side of the victim, if possible, blocking his nearest arm). After that you should check
victim's reaction to pain when pressed between his first and second fingers or squeeze
trapezius muscle of the back. With the other hand, the policeman must provide blocking from
possible aggression. The lack of reaction in the victim indicates that he is unconscious. If
affected in consciousness and adequate (says), it is believed that his airways are open. But consciousness
the victim should be put on his back, carefully open his mouth and examine the oral cavity for the presence
of
foreign bodies, blood, mucus, vomit. If foreign bodies are found - tilt your head
victim to the side and clean the contents of the oral cavity with a bandage or cloth of clothing,
making circular motion clockwise or counterclockwise with your fingers. To protect the savior's fingers
from
bites should squeeze the victim's cheek between his teeth or insert some tissue there. For opening
the respiratory tract using Safar, according to which it is necessary: - to throw back the victim’s head
back; - open his mouth; - bring down the lower jaw. This manipulation closes the entrance to the esophagus
the victim, raises the root of his tongue and opens the trachea, which allows him to breathe, and
to the savior - to determine the presence / absence of independent breathing in th e victim. When
suspected damage to the cervical spine is prohibited to move the victim’s head. On this
indicates the so-called rule of six "B": "driver" (traffic accident), "water"
(diving), “height” (falling from a height), “explosion”, “gallows”, 15 “electric shocks”. In this case
it is only necessary to bring down his lower jaw. The next step in the initial inspection is to check
the presence of the victim’s breathing according to the “see, hear, feel” method, which consists in: -
see the movements of his arm and chest of the victim; - hear breathing by the ear; - feel your breath
cheek. To complete this task, keep one hand on the victim’s forehead (to avoid
straightening the straightened neck), and the other - put on the xiphoid process of the sternum (solar
plexus) and bend your ear to the victim's face. Respiratory efficacy is assessed within 10 s.
It is recommended to count to 10 from the word "500" (500-1, 500-2, 500-3 ... 500-10), so as not to go
astray
the number of breaths the victim has. The norm of breathing consciousness is considered the amount of two
to five breaths per
10 sec Moreover, it should be borne in mind that the normal respiratory rate in an adult is 12-18 breaths per
minute, and the child - 20-30. Depending on the data received, certain tactical
situations involving an appropriate algorithm of actions: - if one was detected
chest movement, this should be considered an error or ineffective breathing (it should be considered
that there is no breathing). This result requires rechecking and involves the implementation of cardio
pulmonary resuscitation (tactical); - in case the result is from two
up to five breaths (considering age-related characteristics), this is considered normal breathing, in which
basically it’s not about critical conditions for the body (bleeding, pneumothorax). In the presence of
several victims assisting this victim is not a priority. In particular, he
should be provided with a stable position and monitor the dynamics; - if the result of a breath check
more than five breaths in 10 s, this indicates the presence of life-threatening conditions and
indicates chest injury and the development of intense pneumothorax or internal
bleeding. This option requires the savior to immediately begin a full secondary insp ection, trying
establish signs of pneumothorax or bleeding that were not detected immediately. With absence
signs of life begin cardiopulmonary resuscitation. In an adult - ratio: 2 breaths - 30 taps
on the chest with both hands (palm over the palm of the hand or palms “locked”). In children from a year
and adolescents -
the ratio of 5 inhalations is 30 taps, and then 2 breaths is 30 taps with the base of the palm of one hand. In
children
from birth to 1 year - the ratio of 5 inhalations - 15 taps, and then 2 breaths - 15 taps with two fingers.
Lifeguards are replaced every two minutes. Place of pressing on the chest - in the middle of the chest
cells on the line between the nipples. We carry out before the appearance of signs of life or until the arrival
of the brigade
emergency (ambulance) medical care.
1. Cardiogenic syncope occurs with a decrease in cardiac output; stenosis of the aorta or pulmonary artery,
massive pulmonary embolism, myxoma or thrombus of the left atrium, cardiac tamponade, acute
myocardial infarction, CT, fibrillation
ventricles, complete AV block. severe shortness of breath;
2. Hemodynamic syncope occurs with inadequate arterial vasoconstriction (vasovagal
fainting, postural hypotension, surgical or pharmacological sympathectomy), hypovolemia
(bleeding, Addison’s disease), venous tone drop (overdose of nitrates, ganglioblacotoriv,
diseases of the autonomic nervous system.
3. Syncope with obstruction of the cerebral arteries: s pasm or thrombosis of the arteries, compression of the
vertebral artery,
hyperventilation syndrome. severe shortness of breath;
4. psycho-emotional stress, severe fear;
5.faulty position: stroke, heart attack, cramps, bleeding, hunger, poisoning
determine the presence of breathing;
call a team of emergency (ambulance) medical care;
in the absence of breathing, begin cardiopulmonary resuscitation; see 1st question
if breathing is present, move the victim to a stable position.
First-line drugs:
Adrenaline can be administered 1 mg every 3-5 minutes. It combines alpha and beta adrenergic
properties. His
alpha adrenergic action increases coronary diastolic pressure and subendocardia l
perfusion during cardiac massage. Adrenaline also increases the likelihood of success.
defibrillation. However, the beta-adrenergic effect may be adverse, t. To Increases
the need for oxygen (especially the myocardium) and causes vasodilation. Intracardiac injection
epinephrine is not recommended because it requires interruption of compression and may cause
complications in
the form of pneumothorax, damage to the coronary vessels and cardiac tamponade.
Amiodarone 300 mg is prescribed once if defibrillation is ineffective after administration
adrenaline, then another 1 dose of 150 mg is administered. Amiodarone may be effective if after
cardioversion
VF or VT are resumed; a repeated reduced dose is administered after 10 minutes, then the drug is
administered as
prolonged infusion. Strong evidence that the drug increases hospitalization
survival, absent.
A single administration of vasopressin in a dose of 40 units, valid for 40 minutes, may be
an alternative to adrenaline (adults only). However, it is not more effective than adrenaline and therefore
no longer recommended by the American Heart Association
Associa on's guidelines). However, in the unlikely event of a lack of adrenaline during CPR, it may be
replaced by vasopressin.
Atropine sulfate is a vagolytic drug that increases heart rate and
conduction in the atrioventricular node. It is used for severe bradyarrhythmia and high
degrees of atrioventricular block. It is recommended for asystole.
Calcium chloride is recommended for patients with hyperkalemia, hypermagnesemia, hypocalcemia and
an overdose of calcium channel blockers. Other patients with a concentration of
intracellular calcium is already exceeding the norm; additional administration of calcium can be harmful.
Procainamide is a 2nd-line drug for the treatment of refractory VF or VT. However not
it is recommended to use procainamide for resuscitation of children with cardiac arrest with a lack of pulse
in children.
Phenytoin may occasionally be used to treat FS or VT, but only in cases where VF or VT
developed as a result of intoxication with digitalis preparations and cannot be treated by others
medicines. The drug at a dose of 50-100 mg / min every 5 minutes is administered until
the rhythm normalizes or until the total dose reaches 20 mg / kg.
Lidocaine is not recommended for routine use in cardiac arrest. However he may be
useful as an alternative to amiodarone in VF or VT, which do not respond to defibrillation, (in
children) or after restoration of self-circulation in VF / VT (in adults).
Task21
Patient D., 27 years old, a nurse in the shoulder muscle injected medications prescribed
a doctor. After 5 minutes the patient felt a sharp general weakness, pain behind the sternum.
At the time of examination: consciousness is clouded, respiratory rate - 30 / min., Pulse -
120 / min., Weak filling, blood pressure - 80/50 mm RT. Art.
1. What happened to the victim?
anaphylactic shock
Tela, asthma attack, myocardial infarction, hypertensive crisis.
1. Laying the patient horizontally with raised lower limbs (anti-shock position).
2. Perform peripheral vascular catheterization.
2.1 The introduction of adrenaline in / m inside the outer part of the thigh 0.01 mg / kg solution 1: 1,000 (1
mg / ml). Maximum - 0.5
mg (adult), 0.3 mg (child). If necessary, repeat entry into the protracted 15 minutes.
3. To provide airway patency with the implementation of triple admission P. Safar for
prevent tongue dropping and asphyxiation. If removable dentures are present, x must be removed.
Inhalation of 100% oxygen is immediately established.
4. According to indications, resuscitation measures, including chest compressio n,
artificial respiration, tracheal intubation in the background monitoring of the species suddenly stops
blood circulation (CSC) with
subsequent execution, respectively, of the clinical protocol for cardiac arrest
activities.
5. Further internal administration of drug administration, if necessary hospitalization in
viddulennya int.therapy.
- 0.1% adrenaline 0.1-0.2 ml, diluted in physiological saline sodium chloride (1 ml 0.1%
adrenaline is diluted in 10 ml of isotonic sodium solution
chloride), that is, 1-2 ml of the mixture every 5 to 10 minutes until the course stability of hemodynamics.
- 1-2 l. Sodium chloride 0.9% through a catheter (5-10 ml / kg in the first 10 minutes)
- Prednisolonvide 75-100 mg to 600 mg (1 ml = 30 mg of prednisolone), dexamethasone - 4-20 mg (1 ml =
4 mg),
hydrocortisone - 150-300 mg. If it is impossible to implement venous access, glucocorticosteroid di
administered intramuscularly.
- ascorbic acid 500 mg / day (8-10 ml of 5% or 4-5 ml of 10% solution), troxevasin 0.5 g / day (5 ml
10% solution), sodium etamzilate 750 mg / day (1 ml = 125 mg), the initial dose of 500 mg, then through
every 8:00 to 250 mg
- IV bronchodilators of aminophylline 2.4% 10-20 ml, no-spa 2 ml, alupent (brikanil) 0.05% 1-2 ml (drip)
Isadrine - 0.5% 2 ml subcutaneously.
- Antihistamines: diphenhydramine 1% 5 ml, suprastin 2% 2-4 ml or tavegil 6 ml i / m, pipolfen
2.5% 2 -4 ml sc. These medications should be administered to the patient only after a course
AO stability, since x action can enhance hypotension.
- Protease inhibitors: trasilol (aprotinin) 500 thousand units / 50 ml (administered iv slowly or drip in
200-400 ml of isotonic sodium chloride solution with a maximum speed of 5 10 ml / min),
kontrikal 100 thousand units (w / o slowly or drip in 300-500 ml of isotonic solution,
having prepared it beforehand - dry substance is dissolved in isotonic sodium solution
chloride in the ratio of 1 amp. Contrikalu: 1 amp. solvent (2 ml)).
When there are signs of heart failure, a solution of corglycon 0.06% 1 ml
physiological solution of sodium chloride, furosemide 40-80 mg iv in a stream in saline
sodium chloride (1 ml = 10 mg).
Task22
You are a doctor of the admission department. The EMF team delivered the victim of 67 years in a state of
clinical
of death. Cardiopulmonary resuscitation, chest compression, and artificial respiration started.
After 3 minutes, an electric defibrillator was brought.
1. What is the ratio of compression and artificial respiration?
30 chest compressions with a frequency of 100 compressions per 1 min. followed by two
exhale into the patient’s mouth.
30/2
2. What is the location of the AZD electrodes?
1. Verkhovka of the heart (5 mizhrebir * I on the left along the midclavicular line)
2.2-3 mizhrebir * I am on the right along the parasternal line.
3. The mandatory introduction of which the drug provides for specialized resuscitation
complex (ALS)?
- Adrenaline hydrochloride - 1 mg every 3-5 minutes intravenously (iv) - dilution in physiological
a solution;
- Amiodarone (after 3 ineffective discharges) in an initial dose of 300 mg (dilution in 20 ml of 5% glucose
or
isotonic sodium chloride solution.
Sodium bicarbonate is recommended to be administered at a dose of 50 mmol (50 ml of 8.4% solution) if
stopped
blood circulation associated with hyperkalemia or an overdose of tricyclic
antidepressants.
Calcium chloride - in a dose of 10 ml of a 10% solution for hyperkalemia, hypocalcemia, an overdose of
blockers
calcium channels (II class).
4. In what case is the termination of cardiopulmonary resuscitation possible?
1. Restore self-circulation - the appearance of a pulse on the main arteries
(chest compression stops) and / or breathing (stop ventilation)
2. Ineffectiveness of resuscitation for 30 minutes.
An exception are conditions in which it is necessary to prolong resuscitation: hypothermia
(hypothermia), drowning in ice water, overdose of drugs or drugs,
electric shock, lightning strike;
3. the onset of obvious signs of biological death: the maximu m expansion of the pupils with the appearance
of
called dry "herring shine" due to the drying of the cornea and the cessation of lacrimation;
the appearance of positional cyanosis, primarily - cyanotic coloration appears along the posterior margin of
the ear
shells and the back of the neck, back stiffness of the muscles of the limbs, does not reach the degree of
cadaveric
rigor.
Task23
In victim B., 20 years ago, 20 minutes ago, oral poisoning occurred.
unknown poison.
1. What are some ways to induce vomiting? What complications can arise?
- “Restaurant method” - pressing on the root of the tongue with your fingers.
- Drink a decoction of anise, St. John's wort, thyme (Prepare weak solutions and decoctions of these herbs,
take for one
reception. Necessary to take about 5 glasses of potion)
- potassium permanganate (several crystals dissolve in a two-liter bottle of water, while the liquid
should be warm. The solution is taken completely within half an hour)
An adult needs to drink 500-700 ml (2-3 glasses) of clean, cold (18 ° C) water, then it is necessary
induce vomiting; repeat rinsing until clean rinsing water is obtained.
Complications: burn of the esophagus, rupture of the esophagus, rupture of the stomach, damage to the
vessels of the esophagus and stomach.
2. In what cases can not cause vomiting?
In case of absence / impairment of the patient’s consciousness.
In case of poisoning by cauterizing substances (for example, gasoline).
In the case of varicose veins of the esophagus, tumors of the esophagus, stomach, st rictures of the
esophagus,
diaphragmatic hernia, bronchial fistula.
3. What are the universal antidotes?
enterosorbents
4. The technique of gastric lavage.
The patient is in a half-sitting position.
1. Insert the probe into the stomach (the length of the probe is calculated from the incisors to the navel),
with the introduction of the probe - should
check with reverse air pressure - hear rumbling, if in the airways - the patient coughs)
2. Pour 250 ml of water (in adults) into the body temperature through t he funnel, and before the water
disappears from
funnels, lower over a bucket, below the level of the stomach, will lead to the return of the poured water
(siphon
phenomenon) repeat this repeatedly until clean wash water is obtained. Sometimes the amount of flushing
water can reach 10 liters.
3. The introduction of the last portion of water with added activated carbon should be considered if, from
the moment
poisonous substances took ≤60 minutes, the patient retained laryngeal reflexes or intubation,
and took a potentially toxic dose of a toxic substance, coal adsorbs. Activated Introduction
coal is justified in case of poisoning.
Task24
An unknown was found on the street with no signs of life.
1. What is the duration of clinical death?
3-5 minutes after stopping breathing and blood circulation.
2. In what cases can the last of the terminal states be much longer?
In case of emergency care (artificial respiration, compression of the chest)
3. What is the evidence and how is the symptom of Larsch “herring” d etermined?
This is a biological sign of death, formed within 2-3 hours.
After death, clouding of the cornea and sclera becomes noticeable, and on the conjunctiva
brownish areas of cadaveric drying (Larsch spots) appear, which have a triangular shape and
the base are located in the iris.
They may not form with high humidity in the room.
Visually determined by the expansion of the palpebral fissure and examination of the conjunctiva.
4. What needs to be done before examining the victim?
1. Make fun of environmental safety (visually assess the situation around)
2. Contact, find witnesses.
3. Be careful to approach the victim, do not touch objects, substances that may subsequently
indicate the cause of death.
4. Call the ambulance.
Task25
A 30-year-old man was talking while eating, when he suddenly grabbed his neck. Objectively: face
cyanotic, lack of voice, cough, the victim can not breathe in or out.
Foreign body of the respiratory tract
Receptions of Heimlich.
- Squeeze one of the hands into a fist and with your thumb of a fist press the place of the abdomen of the
victim between
belly button and ribs.
- Put the palm of the other hand on top of the fist and push it upwards, push it into the stomach.
- We repeat the application of the Heimlich method until the complete release of the human respiratory
tract.
It is important to remember that patting the victim on the back can make things worse. Subject by which
the person has choked, from blows on a back it can pass respiratory ways down.
3. What are the main causes of airway obstruction?
Foreign body, impairs the passage of air through the respiratory tract.
4. What complications may arise with emergency care?
Perforation of the wall of the respiratory tract, pneumothorax, atelectasis, bleeding, mediastinal
emphysema,
death.
Task26
During the repair work on the water utility, a leak of chlorine from the storage tanks occurred.
18 people suffered, in which there was a sore throat, lacrimation, coughing, pain in
chest, itching and flushing of the skin.
1. What measures should emergency teams take?
- Remove victims outside the area of action of the poisonous substance;
- provide access to clean air;
- remove contaminated clothing and wash contact skin with warm water;
- in case of eye damage, rinse with plenty of water or a weak solution of soda (1 teaspoonful
spoon on a glass of water)
- rinsing the mouth and nose with a soda solution (1 h ... l. Soda for 1
a glass of water) to minimize damage to the mucous membrane, the use of inhalations with the addition of
soda.
2. How to carry out medical sorting?
- The first (red color) to help those affected whose lives are at risk (lack of breathing,
palpitations, loss of consciousness)
- In the second place (yellow), help the wounded or sick with stable life
indicators
- In the third turn (green color) to those who have a satisfactory state of life
indicators, they have the opportunity to expect emergency care.
- In the fourth place (red) - identification, stating death.
3. Where to hospitalize the victims?
To the IT department.
4. Who should provide first aid in a hotbed of emergency?
Employees of the Ministry of Emergency Situations, the Ministry of Internal Affairs and medical workers.
All first responders trained in basic health care skills.
In the event of an emergency, coordinated action ensures that first aid
provided by medical workers (according to the specifics of medical sorting and evacuation
defeat)
Task27
The victim after a traffic accident found liquorrhea from the nose and ear, bleeding from
nose and mouth, sick unconscious.
1. What is the preliminary diagnosis of a skull base fracture?
2. What conditions should be used for differentiation?
Brain compression, diffuse axonal lesions, brain bruises
3. What emergency measures need to be taken immediately:
- clean the area of the wound circle, treat with iodine;
- apply a sterile dressing;
- put the victim on his back;
- put a roll of clothes rolled up in the form of a ring under the head, put the same rollers on the sides
heads to secure her property;
- if the victim is unconscious, they will return their heads to their sides;
- clean the victim’s mouth from foreign bodies, mucus, vomit;
- if the victim has a sunken tongue, remove it from his mouth and fix it;
- put a cold on your head;
- if there is no pulse in the carotid artery, proceed with indirect heart massage and artificial
breathing.
- hospitalization in the intensive care unit
imaging studies: CT of the head without contrast or MRI, if necessary with the extension
spinal examination;
laboratory tests - OAC, plasma electrolyte and glucose concentration, indicators
coagulation, arterial blood gasometry.
Task28
A boy of 10 rocki was stung by a bee. Objectively: swelling of the lips, face, neck. Complaints of a feeling
of heat i
lack of air. Difficulty breathing, noisy, pinching from the mouth, coughing. The skin is pale
cold. Bradypnoe. Heart sounds are deaf, arrhythmic. Pulse is threadlike.
1. What is the preliminary diagnosis of anaphylactic shock?
2. What conditions should be used for differential diagnosis:
pathological conditions of NS (for example, dizziness), anaphylactoid reactions due to
the release of allergy mediators without a preliminary immunological reaction due to overeating,
excessive consumption of foods high in histamine. Very rarely imitate shock
can coma, different in etiology and pathogenesis, sudden cooling during cold urt icaria, aspiration,
heart attack, embolism, spontaneous pneumothorax, orthostatic collapse, hyperventilation syndrome.
3. What emergency measures need to be taken immediately:
3. Place ice or a heating pad with cold water for 10-15 minutes at the bite site.
4. Limb inject 0.3-0.5 ml of 0.1% adrenaline solution (for children 0.15-0.3 ml).
5. Transportation of patients is carried out after their withdrawal from a threatening state by ambulance
or resuscitation team, since during the evacuation, a repeated drop in arterial
pressure and the development of collapse. Mandatory hospitalization.
4. What medications are used to treat:
1. If the blood pressure does not stabilize, you must immediately begin to drip inside
administration of norepinephrine (or mesatone) 0.2-1.0-2.0 ml 500.0 ml of 5% glucose solution.
2. intramuscularly or intravenously inject GCS drugs: prednisone 60-120 mg (children 40-100 mg),
dexamethasone 8-16 mg (children 4-8 mg) or hydrocortisone succinate or hemisuccinate 125-250 mg
(children 25-125
mg).
3. intramuscularly introduce 2.0 ml (children 0.5-1.5 ml) of a solution of tavegil 0.1% or suprastin 2.5%
under control
blood pressure.
4. When bronchospasm is administered intravenously 10.0 ml (children 2-8 ml) of a 2.4% solution of
aminophylline in a 0.9% solution
sodium chloride or dexamethasone (20-40 mg).
5. Cardiac glycosides, respiratory analeptics (strophanthin, corglycon, cordiamine) are administered
according to indications.
Task29
The victim has venous bleeding from a cut wound of the forearm.
1. What are the signs and characteristics of venous bleeding?
Signs of venous bleeding: blood slowly flows from the wound, dark red in color depending on
the diameter of the damaged vein, bleeding can be from minor to intense.
Venous blood flows from the wound in streams, continuously, evenly, and rather slowly. If
large vessels are damaged, in which increased fluid pressure, the blood pours profusely, but with
this (unlike arterial), it does not pulsate in the rhythm of the heart.
2. What methods do you know to determine the amount of blood loss at the prehospital stage?
Algover index = heart rate / syst.AT (normal 0.5-0.7).
Algovera Index Blood loss (in% of BCC)
0.8 and less than 10%
0.9-1.2 20%
1.3-1.4 30%
1.5 and more than 40%
3. At what blood loss is hemorrhagic shock possible?
The development of hemorrhagic shock is caused by blood loss of 1000 ml or more, which means a loss of
20%
Bcc.
4. What method of hemostasis is appropriate to apply?
The physical method of hemostasis.
Task30
The patient was diagnosed with a fracture of the pelvic bones.
1. What is the estimated volume of blood loss?
The average blood loss during fractures of the anterior half ring is about 1 liter, with double
fractures of the anterior and posterior half rings (Malgen type) - 1.5 - 2 l, with multiple fractures - 2.5 - 3 l
and more
conduct anti-shock therapy: 1. Introduction of 2 ml of 1% solution of promedol.
2. Anesthesia with narcotic or non-narcotic (nalbuphine)
3. Immediate installation of an intravenous transfusion system for anti-shock fluids (best
method - catheterization of the subclavian vein).
4. intrapelvic anesthesia for schoolchildren - Selivanov. Pelvic Fractures
the anterior and posterior pelvic ring (Malgen type) are treated with a skeletal traction system or
external fixation devices.
3. In what position should the victim be transported?
It is necessary to ensure the position of the patient on a solid surface in the "frog position". Antishock
events transporting to the hospital.
Diagnosis is based on the identification of symptoms characteristic of damage to the pelvic skeleton, x-ray
research
Task31
Injured S., 17 years old, in a traffic accident received a closed fracture of the middle third
the femur.
1. How much blood loss is possible with this localization of lesions?
0.5-1.5l.
Anesthesia, antishock therapy, transport immobilization
1. The introduction of 2 ml of 1% solution of promedol.
2. Anesthesia with narcotic or non-narcotic (nalbuphine)
3. Immediate installation of an intravenous transfusion system for anti-shock fluids
4. Interpretation of laboratory examination results.
OAC, OAM, myography, rheovasography (study and determination of the state of the neuromuscular
system)
joint puncture, muscle biopsy.
Task32
The victim N. 54 years old, was diagnosed with clinical death. You started with an assistant
cardiopulmonary resuscitation. After 40 minutes, the victim is unconscious, there is no breathing.
1. What happens to the victim?
biological death
2. The procedure for conducting the basic resuscitation complex by 2 rescuers.
The ratio of chest presses in artificial breaths is 30: 2. Resuscitation should be started with
clicks on the chest. The frequency of clicks should be 100-120 in one minute, and squeeze the chest
the cage needs 5-6 cm. After each compression, it is necessary to wait for the chest to expand, with
this must try to minimize breaks between onslaught. At runtime
artificial respiration, inhalation should be done for 1 second, exhaling a volume of air sufficient to
visible expansion of the chest. Do not stop indirect heart massage for more than 10 seconds.
3. Conditions for the termination of cardiopulmonary resuscitation.
resuscitation failure for 30 minutes
onset of obvious signs of biological death
4 A sign of biological death.
• Lack of consciousness.
• Lack of manifestations of breathing.
• Lack of pulse on the main vessels (femoral and carotid arteries).
• Violation of cardiac activity.
• Dilation of the pupils, their lack of response to light.
Task33
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A 37-year-old man was injured with a knife an hour ago. Objectively: general state of moderate
severity. Leather
pale. Pulse 80 beats per minute, At 115/70 mm On the front surface of the middle third of the left leg
a cut wound is visualized. The left thigh was bent over by a belt. When loosening the belt
bleeding.
Venous bleeding.
The elimination of blood loss is carried out using a pressure bandage.
Pressing the dressing is applied just below the damaged area, since venous blood is transported
to the heart of peripheral vessels.
If it was possible to stop the blood, and the ripple below persisted, then the crushing bandage was applied
correctly. If
the blood continues to flow, and the bandage again began to sag, then a few more should be applied on top
layers of gauze (bandage, napkins) and again tightly bandage.
If there is no tight bandage at hand, the bleeding area should be pressed with your fingers. Harness at
venous bleeding is imposed only with severe blood loss. The harness is also superimposed below
injured on top of clothes or dressings. Be sure to write a note indicating the overlay time
harness. It is forbidden to keep the tourniquet for more than 15 - 2:00 - you should remove it for several
minutes, crushing it
damaged wound with fingers.
Vasoconstrictor drugs. They are based on spasm of the vessel and increased blood coagulation. To these
drugs include adrenaline, norepinephrine. Depending on the type of bleeding, these medicines
apply topically, parenterally or orally.
The preparations of the second group of biological hemostatic agents include freshly prepared blood,
fibrinogen, plasma, cryoprecipitate, antihemophilic globulin, antihemophilic plasma. These drugs
mainly administered parenterally (iv)
ZAK
The intensity is relatively low.
Blood is released by the stream, but it does not pulsate.
The color of the blood that is released from the wound is dark cherry.
Task34
A 22-year-old man fell from a height of 7 meters. Objectively: the right lower limb is rotated outward,
shortened, angular deformation is visible in the middle third of the thigh. On palpation is determined
soreness and pathological mobility in the middle third of the thigh.
1. Preliminary diagnosis: fracture of the diaphysis of the femur, middle th ird with a shift.
2. Immediate: anesthesia, immobilization of the film with Diterichs bus or 3 tires
Cramer. Transportation to a hospital on a solid shield (spinal injury?)
a. Skeletal extraction, in / in (fastening with metal plates, rod
devices, extra focal osteosynthesis)
3. In the hospital - anti-shock therapy (anesthesia), infusion therapy, recovery
blood loss.
4. Examination general examination, visual inspection, determination of limb function. X-ray in
2 projections.
Screening for the presence and degree of blood loss
Standard preoperative tests (OAK, OAM, blood type and rhesus, coagulogram, blood sugar,
platelets, RW, ECG)
Task 35
A policeman is injured in the chest. Complaints of pain in the right side of the chest, shortness of breath,
coughing produces blood. Objectively: the face and lips are cyanotic. In the area of VIC-VI and ribs to the
right of the wound
5x8 cm in size. When inhaled, the sound of air is heard, absorbed. The number of breaths is 40 per
minute. Pulse 140
beats per minute. AO 70/50 mm Hg
1. Preliminary diagnosis: Right-sided strained pneumothorax, lung injury?. Shock III art.
2. Tactics: emergency hospitalization
a. with bleeding - stop bleeding and treat shock
i. vascular access 18 G IV or IV bolus 500 ml (HES solution (6%) or solution
electrolytes). If possible - blood products.
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ii. If signs of shock persist - +500 ml of 6% HES or electrolytes. Infusion
therapy with the goal of CAT - 80-90mm Hg, heart rate less than 100.
b. occlusive dressing (subject to increased signs of intense pneumothorax - +
needle decompression; ineffective - drainage of the pleural cavity)
3. preparations:
a. Infusion ter: HES 6%, electrolyte districts, blood products (FFP, red cell mass)
b. Pain control (narcotic analgesics may be contraindicated through respiratory depression.
Ketamine 20 mg iv d)
c. antibiotic therapy
d. Tranexamic acid (1 g of tranexamic acid in 100 ml of 0.9% sodium chloride solution or
Ringer patch on / in for 10 minutes.) If less than 3 hours from injury.
In the hospital - iv, suturing a wound to the lung and chest, drainage of pleura.
Task36
In the center of a natural disaster, the des truction of a container with a chemical substance occurred. Injured
complains of dizziness, tinnitus, throbbing in the temples, severe pain in the heart. In 10 minutes
before that I smelled bitter almonds. Objectively: the skin is red. The pupils are dilated,
exophthalmos. Pulse 50 beats per minute. AO - 140/80 mm Hg
1. Preliminary diagnosis: hydrocyanic acid poisoning
2. Tactics - evacuation of the victim in accordance with the equipped rescuers), antidote,
anticonvulsant therapy, respiratory support.
a. Inpatient - mechanical ventilation, repeated administration of antidotes, antibiotics, desensitizing
agents, hyperbaric oxygenation.
3. preparations:
a. oxygen therapy 100% oxygen
b. hydroxycobalamin antidotes - iv infusion 5 g for 15 min, depending on severity
poisoning and reaction to treatment, you can enter a second dose of the drug
c. sodium nitrite (amp. 20 mg / ml) iv 300 mg for 5-10 min (≈30 min after administration
leads to the formation of methemoglobin, which combines with cyanides), and the next step is
sodium thiosulfate (25% solution in amp.) 12.5 g (50 ml of a 25% solution) iv for 15-20 minutes
(causes conversion of cyanides to thiocyanates excreted by the kidneys)
d. Methylene blue? Ampoules of 20 ml. Introduce 1-2 ml / kg iv. Up to 60-80 ml.
4. Analyzes are not indicative. After the introduction of antidotes - methemoglobinemia
Task37
A 63-year-old woman received burns on her face, chest, and upper arms as a result of the explosion of a
household gas cylinder
limbs. Objectively: the skin of the face, chest, upper extremities is hyperemic. There are areas with thin
a light brown scab of up to 3 palms and numerous bubbles that burst.
1. Diagnosis: moderate burn disease
2. Burns of the 1st century (36% of the body surface), III Art. - 3% of the body.
3. The severity index of the lesion 36 + 9 = 45 (burn disease of moderate severity). Exclude !!
burns of the respiratory tract.
4. Emergency care:
a. cooling of the affected areas
b. Rospocnit infusion resuscitation, introducing a solution of sodium lactate at an initial rate,
determined by the modified Parkland formula, and adjust according to diuresis
3-4 ml × kg ×% STD custody = ml iv infusion must be administered within 24 hours after
for burns Enter 1/2 of this volume within the first 8 hours of receipt
burns Enter 1/2 of this volume over the next 16 hours Diuresis is necessary
maintain at 0.5 ml / kg / h
c. analgesia (morphine 2.5-10 mg cb page)
d. aseptic dressing. Next - hospitalization in the burn department
Task38
A 45-year-old man accidentally poured a bucket of boiling water on himself. Objectively: both shins and
the right thigh
hyperemic, very painful. Here and there, small blisters filled with
transparent content. The pulse is 85 beats per minute. AO - 130/90 mm Hg
1. burn disease
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2. Burns II Art. (27% of the body surface).
3. survey program
Determination of the presence of burn shock and the need for hospitalization of the patient in the intensive
care unit and
intensive care.
4. Laboratory tests - blood clotting? due to fluid loss.
Protocol ( order of the Ministry of Health No. 691 of 07-11-2007)
a. Laboratory examination:
i. general blood analysis
ii. general urine analysis;
iii. blood glucose
iv. biochemical blood test
v. coagulogram;
vi. determination of blood group and Rh factor;
vii. Wasserman reaction.
b. Identification of concomitant diseases.
c. X-ray examination of the lungs according to indications.
d. ECG for adults.
5. Treatment program (order of the Ministry of Health No. 691 of 07 -11-2007)
a. Anesthesia - non-narcotic analgesics.
b. Hormone therapy - glucocorticoids.
c. Cephalosporins antibiotics I generation.
d. Infusion detoxification therapy. (Daily volume of infusion
calculated according to the Parkland formula:
V infusion = 4 ml ×% burn surface area × patient weight (kg).
e. Dehydration therapy.
f. Anti-tetanus vaccinations.
g. Ensuring ambient temperature in the range 34-36
0
S. Victim
placed in a box on a bed-net under a source of infrared radiation.
Local treatment:
● Daily dressings for 20 days.
● - primary toilet of a burn wound using antiseptic solutions;
● - in the phase of inflammation, the use of ointments on a hydrophilic hyperosmolar basis,
dressings with antiseptic solutions;
● - in the granulation phase - creams or ointments on a hydrophilic basis are used.
● - In the regeneration phase, creams, ointments on a water-soluble basis with
decreased osmolarity and regenerating ointments.
Surgical treatment:
Early sequential necrectomy (2-5 days) with simultaneous closure of wound
defect by lyophilized xerotransplant or other biological and
composite synthetic materials.
Task39
A 40-year-old man during exercise suddenly felt suffocation, pain in the left side
chest, palpitations. Objectively: a serious condition, blood pressure - 100/70 mm Hg, heart rate - 100
1 min., Breathing - 28 in 1 min., The left side of the chest lags behind in the act of breathing, percussion -
on the left
high tympanitis, auscultation - in the lungs on the left, breathing is significantly weakened.
1. Preliminary diagnosis: Left spontaneous stressful? pneumothorax.
2. immediately:
● Oxygen
● (with intense! Pneumothorax) B guide the catheter into the pleural cavity through the II intercostal space
a gap along the midclavicular line (along the upper edge of the III rib) using a catheter
(identical as for peripheral veins) 4-5 cm long and 2.0 mm (14 G) in diameter or 1.7 mm (16 G)
and leave it until you enter the drain.
examination
a. 1) Chest WG shows lung displacement from the chest wall
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b. Pulse oximetry and arterial blood gasometry: SpO reduction
2
and hypoxemia
(especially with intense and large pneumothorax), sometimes hypercapnia and
respiratory acidosis (especially with secondary pneumothorax).
c. ECG
Hospitalization in the thoracic department to address the issue of drainage
d. Drainage of the pleural cavity through the intercostal space: drainage introduced into
pleural cavity, connect the trihampule set and leave until full
straightening the lung or stopping the passage of air through the drainage. If, despite
drainage, the lungs do not straighten, apply active aspiration.
d. Treatment - anesthesia (non-narcotic analgesics), Antibiotic prophylaxis.
Task number 40
The ambulance crew was summoned to a country house by a woman, 45 years old, who, while working
accidentally grabbed a bare electric wire with her right hand, fell and lost consciousness. At
examination: injured unconscious, skin is pale, heat, breathing is absent, pulsation on the main
vessels are absent. There are two black spots on the skin of the right palm.
1. Electrotrauma complicated by cardiovascular failure.
2. emergency care
a. Put on your back, free your mouth from foreign objects and hold
artificial lung ventilation (mechanical ventilation).
b. At the same time, an indoor cardiac massage (OMS) is performed. Mechanical ventilation and
compulsory medical insurance continue
until spontaneous breathing is fully restored in the victim and NOT
blood circulation is normalized.
c. These activities must be carried out at the scene of the disaster o r during
transporting the victim to a medical facility.
Emergency hospitalization, dynamic monitoring of ECG and basic indicators of homeostasis.
3. Analgesic therapy includes: tramadol 1-2 mg / kg or renalgan 0.5-5.0 ml,
Polarizing mixture (panangin 50 - 80 ml, insulin 6 - 8 units, 10% glucose solution 150 ml.),
Coronarolytics and antiarrhythmic drugs.
Task41
Patient G., 50 years old, a bus driver who slept in the cabin the night before, turned to the hospital
a car with the engine turned on to keep warm. In the morning I felt a headache, weakness,
dizziness, tinnitus, nausea. Objectively: the face is hyperemic, respiratory rate 22 per minute,
pulse - 86 beats. / Min., Blood pressure - 100/70 mm RT. Art.
1. The preliminary diagnosis is carbon monoxide poisoning (MKB-10 - T58), mild.
2. Emergency care tactics at the prehospital stage: immediately remove the victim from the area with
increased concentration of carbon monoxide. Ensure the free passage of the upper
airway, release from squeeze clothing. Provide peace and warmth, maintain
verbal contact.
Hospital care tactics -
Inhalation of oxygen or an oxygen-air mixture using artificial medical devices
lung ventilation DP-10.02, DAR-05, phase-5, or oxygen inhaler KI-4.02 should start from the first
minutes of assistance. At the same time, they suggest inhaling 100% oxygen, for 3 hours - 80-90%
oxygen-air mixture.
Of great importance is the use of oxygen under pressure (oxygenobarotherapy) - hyperbaric
oxygenation for 1.5-2 hours with a pressure of 1.5-2 atm up to 4 times a day.
3. drug therapy
- the introduction of 6% acizole 1 ml intramuscularly immediately after removal of the victim from the
fire. After
acizole is administered 1 ml 2-4 times a day. For therapeutic purposes, the drug is administered orally 1
capsule 4 times a
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the first day, and for 7 days - 1 capsule 2 times a day. For prophylactic purposes appoint 1
capsule inside 20-30 minutes before entering the smoke zone. The protective effect of acizole is maintained
on
for 2-2.5 hours. Clinical studies have shown that acizole as a zinc-containing drug
prevents the formation of carboxyhemoglobin by acting on cooperative interaction
subunits of hemoglobin, due to this, the relative affinity of hemoglobin to carbon monoxide decreases,
improves oxygen-binding and gas transport properties of blood. (A. Grebenyuk, V.A. Barinov, V.A.
Basharin, 2008)
- cytochrome C 20 mg to 40-80 mg / day, intravenously (cytomac) / therapy of histotoxic hypoxia /.
symptomatic therapy: upon excitation - 1% solution of promedol 1 ml subcutaneously or intravenously,
2.5%
chlorpromazine solution 2 ml intramuscularly, with convulsions - 0.5% diazepam solution 2 ml
intravenously.
4. Diagnosis of acute carbon monoxide poisoning. The absolute sign of acute CO poisoning
is the presence of high levels of HbCO in the blood. However, it should be borne in mind that
the diagnostic significance of this indicator and skin color is large only when dete rmining
them at the place of poisoning. Otherwise, dissociation of carboxyhemoglobin (with early
oxygen therapy) leads to a mismatch of its content in the blood and clinical symptoms.
The bright red color of venous blood, hyperglycemia, has a certain diagn ostic value.
positive express tests for carboxyhemoglobin (Kunkel-Weizel test with 3% tannin solution,
spectroscopic test, blood thickener color comparison test with control), increased content
in the blood of non-hemoglobin iron in the plasma, deviations of the porphyrin metabolism (increased
content
protoporphyrin in red blood cells, excretion of delta-aminolevulinic acid and coproporphyrin with
urine). A decrease in the activity of enzymes is also characteristic: catalase, cytochrome oxidase,
serum glutathione peroxidase. In case of severe poisoning, oliguria, glucosuria,
sometimes acetonuria.
content
carboxy
hemoglobin in
blood
Clinical signs
to 10%
general weakness, fatigue during physical exertion
10-20%
zapamarochennya while driving, minor headache
20-30%
intense headache, agitation, hypertension, fatigue,
confusion
40-50%
significant headache, collapse, hypertension, loss of consciousness
60-70%
fainting, death possible
> 80%
coma, quick death
Task42
A 25-year-old man choked while eating. You have started performing subphrenic
shocks, but to no avail. After 4 minutes, the victim lost consciousness and fell to the ground. Objectively:
the face is pale, consciousness and breathing are absent.
3. Basic resuscitation complex without the use of an automatic external defibrillator.
1. Preliminary diagnosis - Clinical death (as a result of mechanical asphyxiation)
2. Emergency care tactics - Ask others to call 103 and call the ambulance team.
If there are no people around, call 103 yourself, putting the phone into loud speech mode and putting it in
front of
by myself. In the presence of a protective mask-valve, carry out 5 rescue breaths to the victim, and
start CPR immediately.
3. The basic complex of resuscitation measures:
1) make sure that there is no danger before providing assistance;
2) if the victim does not respond:
a) turn to people who are nearby with help;
b) if the victim lies on his stomach, return him to his back and restore airway
c) to restore airway patency, determine the presence of breathing using the “hear,
see, feel. " Determine the presence of breath within 10 seconds. If in doubt, there are
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breathing, consider that there is no breathing;
3) if the victim is breathing, in the absence of consciousness:
a) move the victim to a stable position;
b) call a team of emergency (ambulance) medical care;
c) provide supervision over the victim until the brigade of emergency (ambulance) medical care arrives;
4) if breathing is absent:
a) call a team of emergency (ambulance) medical care;
b) start cardiopulmonary resuscitation:
perform 30 clicks on the chest with a depth of at least 5 cm (no more than 6 cm), with a frequency of 100
clicks (not
more than 120) per minute;
perform 2 breaths using a valve mask, a breathing mask, and the like. With absence
protective means you can not perform artificial respiration, and conduct only pressure on the chest
the cage. Two breaths should last no more than 5 seconds
after two breaths, continue pressing the chest in accordance with the above scheme in this
subparagraph;
5) change the face, presses the chest, every 2 minutes;
4. To stop conducting cardiopulmonary resuscitation is possible in the following cases:
1. The victim was breathing / coughing / exhibiting motor activ ity, while checking breathing you
heard more than 1 breath in 10 seconds.
2. The arrived team of SMP, and replaced you.
3. You are physically tired and cannot continue CPR, while there are no people who could replace you, and
no
signs of CPR effectiveness within 30 minutes.
4. It has become dangerous for you to remain with the victim.
Task43
At the airport, you saw a man who lost consciousness. On examination: the skin is pale,
breathing and consciousness are absent, the pulse on the carotid artery is not d etermined. Near the wall is
automatic external defibrillator.
3. Basic resuscitation complex using an automatic external defibrillator.
1. Preliminary diagnosis - Clinical death
2. Emergency care tactics - Ask others to call 103 and call the ambulance team.
If there are no people around, call 103 yourself, putting the phone into loud speech mode and putting it in
front of
by myself. If there is an automatic external defibrillator, apply it immediately.
b) if the victim lies on his stomach, return him to his back and restore airway
4) if breathing is absent, begin cardiopulmonary resuscitation and bring external
automatic defibrillator;
5) open the defibrillator cover. If the automatic defibrillator does not turn on automatically,
turn it on yourself;
6) follow the voice guidance of the automatic defibrillator:
a) stick electrodes on the chest of the victim;
b) wait until the apparatus performs a rhythm analysis;
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c) press the discharge button for defibrillation, provided that no one is injured
touches;
7) after defibrillation, start / continue cardiopulmonary resuscitation in
ratio of 30 clicks on the chest, 2 artificial breaths;
8) comply with the voice prompts of the external automatic defibrillator at all times
cardiopulmonary resuscitation;
9) when restoring signs of life in the victim, ensure constant monitoring until arrival
brigades of emergency (ambulance) medical care. Leave the electrodes on the chest
10) with repeated cardiac arrest before the arrival of the emergency (ambulance) medical care team
carry out the sequence of actions provided for in subparagraphs 7-11 of this paragraph.
4. To stop conducting cardiopulmonary resuscitation is possible in the following cases:
1. The victim was breathing / coughing / exhibiting motor activity, while checking breathing you
heard more than 1 breath in 10 seconds.
2. The arrived team of SMP, and replaced you.
3. You are physically tired and cannot continue CPR, while there are no people who could replace you, and
no
signs of CPR effectiveness within 30 minutes.
4. It has become dangerous for you to remain with the victim.
Task44
A 18-year-old guy ducked from a bridge into a river, after which he could not swim
independently. Strangers
witnesses stretched ashore. Objectively: consciousness is absent, the skin is pale and cold, breathing and
the pulse on the main vessels is not determined.
1. Preliminary diagnosis - Clinical death, damage to the cervical spine
(spinal cord injury).
2. Drowning. Diagnosis should be carried out after resuscitation.
b) if the victim lies on his stomach, return him to his back and restore airway patency
ways. If the victim is likely to have a cervical spine injury, ask others.
impose on him a collar from improvised materials to fix the cervical spine;
4) if breathing is absent:
a) call a team of emergency (ambulance) medical care;
b) start cardiopulmonary resuscitation:
perform 30 clicks on the chest with a depth of at least 5 cm (no more than 6 cm), with a frequency of 100
clicks (not
more than 120) per minute;
perform 2 breaths using a valve mask, a breathing mask, and the like. With absence
protective means you can not perform artificial respiration, and conduct only pressure on the chest
the cage. Two breaths should last no more than 5 seconds
after two breaths, continue pressing the chest in accordance with the above scheme in this
subparagraph;
5) change the face, presses the chest, every 2 minutes;
4. When conducting a RDS, it is possible to use the following drugs:
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-1 ml of a 1% solution (0.5 mg) of iv adrenaline, if necessary, repeat the administration every 3-5 minutes.
In the absence of venous access, adrenaline is administered endotracheally 2-2.5 mg.
- 150 mg (2.5 mg / kg) of amiodarone i / v jet, in its absence - 120 mg (1.5 mg / kg) lidocaine i / v,
which is less effective than amiodarone (ALIVE studies)
Task45
The victim L., 26 years old, has a thermal burn of the left forearm and shoulder, a fracture of the right
thigh.
Objectively: the face is pale, respiratory rate 23 per minute, pulse - 100 beats. / Min., Blood pressure -
100/60 mm RT. Art.
4. Determine the tactics of emergency care.
1. Clinical diagnosis - Primary: Burn of the left forearm and forearm, Complications - Burn shock
moderate severity; Associated - fracture of the right thigh
2. According to the rule of nine - the area of the arm of an adult is approximately 9% of the total area
body surface. It is also known that the area of the palm print is approximately equal to 1% STD. So how are
u
burn the forearm and shoulder, and the hand and fingers are not damaged then the burn area of the victim
approximately 7% of the total surface area of the body (the brush is 2%, 1% in the back and palmar
surfaces).
3. From the conditions of the problem it is impossible to indicate the degree of burns. Perhaps a picture
with
image of a burn.
Burns of the first degree are manifested by redness and swelling of the skin (persistent arterial hyperemia
and
inflammatory exudation).
II degree burns are characterized by the appearance of blisters filled with a clear yellowish liquid. In
deflated by the epidermis remains its bare basal layer.
Burns of the III degree are divided into two types: burns of Sha degree and III b.
Sha degree burns (dermal) - this is damage to the skin, but not to its entire depth (thickness), often
the lesion is limited to the growth layer of the epidermis, sometimes the dermis is dead
while maintaining its deeper layers, elements and skin appendages. With burns IIIB degree necrotic
the entire thickness of the skin and a necrotic scab is formed.
Burns of the fourth degree are accompanied by necrosis (necrosis) of not only the skin, but also deeply
located
tissues - subcutaneous tissue, fascia, tendons, muscles, bones.
4. With limited burns with boiling water, the burn surface is cooled with cold tap water in
within 10 minutes After this, an aseptic dry dressing is applied using an individual package,
bandage, clean cotton. The treatment of the burned should be pathogenetic. Main link
pathogenesis - necrosis of the skin, so recovery can occur after spontaneous
epithelization or restoration of the skin by the surgical method. At the same time necessary
treat burn disease, taking into account the peculiarities of its course. Complex burnt treatment
and includes: general therapy, topical treatment of burn wounds and surgical methods.
The number of transfusion agents per day is calculated according to the Evans formula (3 ml × burn area ×
mass
body), but not more than 10-12% of body weight. In the first 8 hours, half the daily volume of transfusion
is administered
funds.
The ratio of the components of the transfusion drugs depends on the severity of the sho ck. With a slight
shock
(Frank index - 30) the ratio of colloidal, salt and salt-free is 0.5: 1: 1, with an average
severity (Frank index 31-60) - 1: 1: 1, with severe (Frank index - 61-90) - 1.5: 1: 1,
in extremely severe cases (Frank index more than 90) - 2: 1: 1. It is advisable to start anti-shock therapy
with
jet introduction of balanced electrolyte solutions (Acesol, Disol, Trisol, etc.). this
provides rapid filling of the vascular bed, especially venous, adequate cardiac output,
prevents spasm of blood vessels. After filling the vascular bed with electrolyte solutions,
colloidal plasma substitutes, because they contain fluid in the vascular bed, 16 detect
rheological, disaggregant and detoxifying effects, reduce blood viscosity. Rate of introduction
transfusion agents during the first hours after a burn is crucial for elimination
pathophysiological changes in shock.
Quick recovery of the volume of the vascular system eliminates spasm of blood vessels, reduces blood
viscosity,
acidosis, improves myocardial activity. Along with transfusion therapy, normalizes work
hearts and
vascular tone (corglucon, strophanthin, dopamine, trental, chimes, etc.). To normalize metabolism
it is necessary to eliminate acidosis (sodium bicarbonate - 4.5% - 200-300 ml, lactasol, trisamine 200-300
ml),
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carry out desensitization (diphenhydramine, suprastin, pipolphene), lower protein proteolysis (trasilol,
contracal,
gordoks), replenish energy reserves (glucose, vitamin C, B1, B6). Amplification of diuresis is carried out
osmodiuretics (10-15-20% mannitol solution), saluretics (2% Lasix solution). Required
take into account the need for the adminis tration of corticosteroid hormones t (prednisone up to 100 mg,
hydrocortisone
150-200 mg) due to acute adrenal insufficiency, and in oxygen therapy. For decreasing
hypercoagulation, blood viscosity and improvement of the rheological properties of blood administration is
indicated for severe
burn shock heparin
5 thousand units 5-6 times a day, antiplatelet agents (chimes, 2.0 ml three times a day, trental 0.5 ml twice a
day),
fraksiparin 3.0 ml twice a day or Fragmina once a day. To reduce the phenomena of proteolysis, they are
administered
protease inhibitors, trasylol, kontrikal, gordoks up to 100 thousand units per day.
Task46
The victim R., 32 years old, burns with sulfuric acid of the left thigh. The burn area is about three palms.
Objectively: a normal-colored face, a respiratory rate of 18 per minute, a pulse of 86 beats. / Min., Blood
pressure - 130/80 mm RT. Art.
4. Determine the tactics of emergency care.
1. Basic - chemical burn of the left thigh (sulfuric acid) 3% STD
2. 3% of the total body surface area in accordance with the rules of the palm.
3 .. From the conditions of the problem it is impossible to indicate the degree of burns. Perhaps a picture
with
image of a burn.
Burns of the first degree are manifested by redness and swelling of the skin (persistent arterial hyperemia
and
inflammatory exudation).
II degree burns are characterized by the appearance of blisters filled with a clear yellowish liquid. In
deflated by the epidermis remains its bare basal layer.
Burns of the III degree are divided into two types: burns of Sha degree and III b.
Sha degree burns (dermal) - this is damage to the skin, but not to its entire depth (thickness), often
the lesion is limited to the growth layer of the epidermis, sometimes the dermis is dead
while maintaining its deeper layers, elements and skin appendages. With burns IIIB degree necrotic
the entire thickness of the skin and a necrotic scab is formed.
Burns of the fourth degree are accompanied by necrosis (necrosis) of not only the skin, but also deeply
located
tissues - subcutaneous tissue, fascia, tendons, muscles, bones.
4. First aid for chemical burns is to thoroughly rinse the burn surface
water under some pressure until the chemical 8 is completely washed off (odor disappears). Water
not only washes away the chemical substance, but also cools the tissues and, eliminating the exothermic
effect,
prevents the spread of necrosis inland.
Do not use solutions for the chemical neutralization of a cauterizing substance (with an acid burn -
a solution of drinking soda, and in case of a burn with alkalis - a solution of citric acid), because the
neutralization reaction is
exothermic, that is, it occurs with the release of heat, which worsens the pathogenesis of burns.
Task47
A woman who was talking in a cafe with her friend suddenly had a cough, a whistle when she inh aled.
The skin of the face acquired a cyanotic hue, the neck veins swelled.
4. What signs are determined when deciding on the beginning of a basic resuscitation complex (BLS)?
1. The probable diagnosis is a foreign tylodichial tract, incomplete airway obstruction.
2. Bronchial asthma, develops gradually (in a few minutes). The patient has a burdened history.
The treatment tactic is to use bronchodilators.
3. The sequence of actions in the provision of medical care to victims of violation
airway obstruction - obstruction by a foreign body by non-medical personnel:
1) with incomplete airway obstruction:
a) encourage the victim to continue coughing;
b) if attempts to cough were successful, the airway was restored,
inspect the victim, call a team of emergency (ambulance) medical care;
2) with complete airway obstruction:
a) inflict five blows on the back
b) if the obstruction of the airways is not eliminated, perform five abdominal tremors;
c) if the obstruction of the airways is not eliminated, alternately repeat five strokes on the back and five
abdominal tremors;
3) in case of loss of consciousness by the victims:
a) move the victim to a horizontal position;
b) determine the presence of breathing and, in its absence, begin cardiopulmonary resuscitation;
4) to ensure constant monitoring of the victim until the arrival of the emergency team (amb ulance)
medical care.
4. it is necessary to verify the lack of consciousness, then ensure the airway, and
check breathing; if breathing is absent, start cardiopulmonary resuscitation.
Task 48.
A 62-year-old man accidentally drank an unknown solution from a bottle. Objectively: on the oral mucosa
a scab of gray-white color, severe pain in the mouth and behind the sternum, repeated vomiting.
4 Interpretation of the results of an additional examination
1 Organic acid poisoning. Chemical burn of the oral cavity and esophagus 3a degree
(pre-acetic acid)
2 Help tactics are: 1 neutralization of acid residues in the oral cavity, esophagus, slag. 2
Providing adequate pain relief to the patient to prevent pain shock.3 Adequate
infusion therapy to prevent the development of acute renal failure 4.
instrumental diagnostics to determine treatment tactics (therapeutic or surgical).
3. 1 Rinse the mouth with a weak s olution of soda. 2. Vicorostan gastric tube for washing,
using 10-15 liters of cold water. 3. Depending on the severity of the condition, enter painkillers
dipyrone 50% IV in 2 ml 10 ml 0.9% NaCl or Morphine hydrochloride 1% 1 ml per 10 ml 0.9% NaCl IV,
0.1%
atropine in \ m. after gastric lavage, 1-2m tablespoon almagel is introduced into the probe. (or phosphalgel,
maalox or
another coating emulsion of oil) with anestezin 0.2g (novocaine 0.2) and chloramphenicol 0.5 g (or
other antibiotic or antiseptic for enteral use). Antidote therapy. Aimed at
alkalization of blood (t hemoglobinuric nephrosis prophylaxis): sodium bicarbonate 3-8% IV
pledged blood. Glucose 5% i.v.; Forcing diuresis - use of diuretic Furosemide - up to
the onset of sufficient treatment of the patient.
4 A preliminary additional examination can be considered the reaction of soda solution during washing
the oral cavity (CO2 will be released), which makes it possible to understand that the poison is
acid. Additional
examinations are carried out after emergency care. Chest x-ray.
(Watch or available gas) .A few weeks after successful treatment, according to indications
FGDS is performed to determine the presence of strictures in the esophagus.
Urinalysis to determine the functional state of the kidneys.
48. Task 48
A few hours after eating mushrooms, all family members had the following symptoms:
abdominal pain, vomiting, fever, children agitation, delirium.
1 Poisoning with fungal toxins
2 1. Gastric lavage, to remove toxin. 2. Gastric sorbents for binding toxic substances
.3.Infusion therapy and forced diuresis to reduce the concentration of toxins in the blood and their
vivedennya. 4 The introduction of antidotes depending on the form of poisoning in the neuro -vegetative
form
the use of atropine, with hepato-nephrotic - large doses of penicillin.
3 Gastric lavage using a probe with cold water 10-15 liters of water. Using Activated
grind coal 30g mix with 200 ml of water and take in suspension, Enterosgel 45g internally washed down
water, children 15-30 hours. Atropine at a dose of 0.01-0.03 mg / kg body weight, iv. Penicillin at a dose of
1 million. \ Kg
body per day (in 4-6 doses during the first 3 days from the time of consumption of mushrooms)
Hepatoprotective
preparations (in an age dose) Lipamide or Berlition (tab.) At a dose of 15 mg / kg of body per day. GKS
(mainly hydrocortisone) in doses depending on the severity of liver failure:
by ALT level in blood less than 2 mmol \ l - 5 mg \ kg per day from 2 to 10 mmol \ l - 10 mg \ kg per day
more than 10
mmol \ l - 15-20 mg \ kg add. Infusion Reosorbilact 50-70 ml \ kg \ day, NaCl 0.9% 50 ml \ kg \ day
.Furosemide in age-related maximum doses. For necessity, methods of efferent therapy:
hemosorption, exchange plasmapheresis, dialysis treatment. Kontrikal - proteolysis inhibitor of 500,000
KIE rn
in \ in.
4 increase in the level of ALT, AST, bilirubin, a-amylase, urea, creatinine in the LHC;
● decrease in the level of prothrombin index in the coagulogram;
● leukocytosis with a shift in the leukocyte formula to the left, an increase in the level of hematocrit in
ZAK;
● moderate proteinuria with leukocyturia in the AS;
● violation of the level of electrolytes, blood glucose in the LHC - indicate a hepatonephrotic form.
Leukocytosis with a shift of the leukocyte formula to the left in ZAK;
● increased hematocrit in ZAK;
● moderate proteinuria with leukocyturia in the AS;
● violation of the level of electrolytes in the blood in the LHC;
● an increase in blood a-amylase level in the LHC. And the symptoms of neuro-disorders indicate neuro-
vegetative form.
In rare cases, a urine test for fungal spores is used to diagnose a specific type of toxin.
Task49
A 29-year-old man complains of pain, a burning sensation and tingling in the fingers. He worked for 5:00
outdoors at a temperature of -20 ° C. On examination: a sharp pallor of the fingers, hands in the joints
the fingers are difficult, the skin of the fingers is cold to the touch.
1 Frostbite of the hands of the upper extremities 1 tbsp.
2 Isolate the victim from the street in a warm room. Gradual warming of the limbs. Application
warm drinks.
3 The use of drugs with 1 tbsp of frostbite is not advisable. Necessary
gradual passive warming of limbs from room temperature. It is necessary to remove from the victim
cold clothes, give a new, warm. Offer warm tea.
4 Diagnosis of 1 st from 2 is asymptomatic. The second degree is manifested by necrosis of the surface
layers of the skin.
After warming, the affected area turns blue. In the frostbite zone, bubbles filled
clear or whitish liquid. Severe pain appears. Among the common symptoms are observed
fever, poor sleep and appetite.
Task50
Injured K., 47 years old, fell on the street, cannot move independently. Objectively: the left shin in
the lower third is swollen, deformed in the middle third. In the place of deformation, local pain is
determined
and crepitus.
1 Fracture of the diaphysis of the middle third of the left tibia
2 immobilization of the lower limb. Overlay tires impose three stair tires: one on the back
the surface of the lower leg and the surface of the foot, previously bent so that the foot
was at an angle of 90 ° to the axis of the lower leg, the upper end should reach the middle of the
thigh; second and third
superimposed on the outer and inner sides of the limb from the base of the foot to the middle of the
thigh. clothing
and they don’t take off their shoes. Anesthesia 50% analgin solution 2 ml IV in 10 ml 0.9% NaCl, rn
morphine 1% 1 ml per 10 ml 0.9% NaCl IV. Connection to veins and slow administration of 0.9% NaCl
solution, for
quick access to a vein in case of needlessness. Transportation of the patient to the trauma unit for
X-ray diagnostics, and the choice of further treatment tactics.
3 50% solution of dipyrone 2 ml IV in 10 ml of 0.9% NaCl, morphine 1% 1 ml in 10 ml of 0.9% NaCl IV
4 On radiography of the lower extremity there will be a fracture of the diaphysis of the tibia with
displacement
possible fracture of the tibia. In laboratory tests unchanged.
Task51
The victim fell and hit the fireplace with his chest. On examination: breathing is frequent and shallow,
the affected half of the chest lags in the act of breathing. Palpation is sharp
soreness and crepitus at the V level and ribs on the right along the middle axillary line.
4 Interpretation of the results of an additional examination
1 Subcutaneous emphysema case along the middle axillary line in the region of the VI rib, fract ure of the
VI rib on the right
middle axillary line
2 Anesthesia, applying a compressive dressing to the fracture area, transporting the patient to
trauma department, chest x-ray, in the presence of pneumothorax-
active drainage. Likuvannya rib fracture.
3 rn analgin 50% 2 ml in \ in dissolving in 10 ml of 0.9% NaCl, 1% 1 ml of the Morphine hydrochloride
solution in
10 ml 0.9% NaCl i.v.
4 If there is air in the subcutaneous tissue of the neck or chest in case of Po chest, no symptoms
pneumothorax, a fairly conservative treatment. If pneumothorax is present, then active
drainage. Then fracture treatment is performed if necessary.
Task52
In the territory of the recreation park, you found a person who lies on the grass near a bench without
signs of consciousness. On examination: the skin is pale, in 10 seconds - 1 breath.
1 Fainting of unknown etiology
2 With hemorrhagic, ischemic strokes. Severe complications of cardiovascular disease
systems (myocardial infarction). Alcoholic, narcotic intoxication. Disorders of the nervous system.
3Viklikats ambulance. Inspect the place where the patient is, maybe he has objects
that can help diagnose the condition (electrical wires, syringes, alcoholic beverages),
examine the patient from head to toe (examine the pupils, bad breath, skin, the presence of inju ries),
to examine the patient’s bag, if there is one, maybe there are drugs in it that can tell
I catch him. Upon arrival of the ambulance, put the patient on a solid stretcher, measure life
indicators of blood pressure, pulse, frequency of breath. Inserted povitrochids into the oral cavity and
connect a bag to it
Ambu, start the ventilation of the legend. Connect to the vein with the introduction of a 0.9% NaCl
solution, so as not to
saved veins. Transport to the hospital admissions department.
4 0.9% NaCl solution
Task53
Walking along the garages, you noticed a man who lies in an unnatural position
a car with a running engine.
1 carbon monoxide poisoning
2 Call an ambulance for help. First of all, it is necessary to remove the victim to fresh air. Sick
laid on his back, remove tight clothes. The body of the victim is rubbed with vigorous movements. On the
a cold compress is put on the head and chest, you need to bring a cotton wool moistened with ammonia to
his nose.
In case of respiratory disorders, oxygen must be restored before inhalation of oxygen.
pathways (toilet of the oral cavity, the introduction of the duct), conduct artificial respiration before
intubation of the trachea and
mechanical ventilation. In the first hours, pure oxygen is used for inhalation, then
switch to inhalation of a mixture of air and 40-50% oxygen. In specialized hospitals apply
oxygen inhalation under a pressure of 1-2 atm in a pressure chamber (hyperbaric oxygenation)
3 0.5 - 1.0 ml of a 1% solution of lobelin intravenously slowly, 1 ml of a 10% solution of caffeine -sodium
benzoate, with
excitation and convulsions 10 - 20 ml of a 10% solution of sodium oxybutyrate intravenously, 200 - 300 ml
4.2% sodium bicarbonate solution, 400-500 ml of a 10% glucose solution with insulin, 30 ml of a 3%
solution
potassium chloride or 10 ml of panangin 40-50 ml of a 0.5% solution of novocaine intravenously, 10 ml of
2.4%
aminophylline solution intravenously. In order to improve metabolic processes in the central nervous
system
system patients, especially those with severe poisoning, are prescribed vitamins: ascorbic acid (5-10 ml
each)
5% solution intravenously 2-3 times a day), vitamins B1 (3-5 ml of a 6% solution intravenously), B6 (3-5
ml of 5%
solution 2-3 times a day). For the prevention and treatment of pneumonia, antibiotics should be
administered.
4 To determine the severity of the condition, blood saturation, pulse and AT are determined. According to
these indicators
it will be possible to assess the condition of the patient and differentiate with other diseases.
Task54
At the construction site, the mason got quicklime on his face.
On examination: pain and burning sensation in the eyes, lacrimation.
1 Chemical eye burn with alkali
2 In case of eye burns with alkali, rinse them abundantly with running water in large quantities holding
eyelids
open, and then additionally - 2% solution of boric acid or vinegar diluted with water (50
parts of water 1 part vinegar)
3 2% boron acid
4 Diagnose your eyesight a few hours after assisting. And diagnose possible
visual impairment.
Task55
Serviceman V., 19 years old, during an unsuccessful jump from the BPM received a closed fracture of the
middle third
femur?
1. Identify emergency care tactics
1) make sure that there is no danger;
2) conduct a review of the victim, determine the presence of damage, examine the affected limb.
3) call a brigade of emergency (ambulance) medical care;
4) help the victim take a comfortable position (one that causes less pain)
5) Put cold on the supposed fracture zone.
6) fix (immobilize) the damaged limb using standard equipment (tires) or
improvised sticks, boards, pieces of plywood or plastic; Any two solid objects are applied to
limbs from opposite sides on top of clothes and reliable, but not tight (so as not to disturb
blood circulation) are fixed with a bandage or other appropriate improvised materials (belt,
belt, tape, rope). In case of a hip fracture, 3 joints should be fixed (hip,
knee, g / supnevy)
7) enter analgesics.
8) to ensure constant monitoring of the victim until the arrival of the emergency team (ambulance)
medical care;
2. What medications are used for treatment?
Analgesics (with severe pain, an opioid, with mild - paracetamol, infulgan, analgin, ketans)
Anticoagulants (for the prevention of pulmonary embolism - fraxiparin, ciboc, Arikstra.)
Vascular preparations (to improve ICR - pentoxifylline, dipyridamole)
Decongestants (to reduce vascular tissue permeability-L lysine, attracts.)
To improve the rheological properties of blood, rheosorbylact.
Laboratory methods are not informative, the diagnosis is made on the basis of an X-ray examination in
2 projections, CT. (Visualization of bone fragments)
4. What complications may arise?
● severe pain that is not always relieved by painkillers
● thromboembolic complications, congestive pneumonia
● bedsores and related infections through real estate
● varus deformity of the proximal femur, shortening
● Nonunion of bone fragments
● Aseptic necrosis of the neck and femoral head
● Coxarthrosis with pain
Task56
Soldier G., 24 years old, after an unsuccessful parachute jump, had a closed fracture of the middle third
diaphysis of the femur and numerous fractures of the posterior and anterior parts of the pelvic ring.
1. What condition did the victim develop? T ravmatichny shock - this is caused by an injury to the pelvis
and hips,
serious condition, accompanied by s evere dysfunctions of vital organs,
primarily blood circulation and respiration. With wounds and damage to the pelvis, blood loss reaches 2.5
liters,
Hips 1.0-2.5 L
1) make sure that there is no danger;
2) conduct a review of the victim, determine the presence of damage, examine the affected limb. 3)
Assessment of vital functions (respiration, blood circulation) and, if necessary, the beginning
resuscitation measures.
4) call a team of emergency (ambulance) medical care;
5) help the victim take a comfortable position (one that causes less pain)
6) stop external bleeding (if this was not done at the previous stage)
7) Assessment of the severity of traumatic shock and the severity of blood loss.
Algover index (norm 0.5):
AI = heart rate / blood pressure
syst.
8) insert a catheter into a vein (if this has not been done before). This event is required in
case when the victim is diagnosed with a traumatic shock of the II degree of severity and higher. With
severe
wounds and signs of severe blood loss (III-IV class) often need to catheterize 2-3 veins in order
to infuse at a high rate;
9) start the infusion of crystalloids (0.9% NaCl, Ringer's solution, rheosorbylact).
10) anesthetize with a narcotic analgesic.
11) Put cold on the supposed fracture zone.
12) fix (immobilize) the damaged limb using standard equipment (tires)
or improvised sticks, boards, pieces of plywood or plastic; Any two solid objects
applied to the limb from opposite sides over the clothes and reliably, but not tight (so as not to
disturb circulation) are fixed with a bandage or other appropriate improvised materials
(belt, belt, tape, rope). In case of hip fracture, 3 joints should be fixed (hip,
knee, g / supnevy). + in case of pelvic fracture, the victim must be laid on a flat, firm
surface in the "frog position". To maintain this position during transfer under the knees
the patient should put a roller out of clothing.
9) ensure constant monitoring of the victim until the arrival of the emergency team (ambulan ce)
medical care;
3. What drugs are used to treat? The volume of infusion depends on the severity
traumatic shock. In case of shock of the II degree or more, before transferring the patient to the operating
room
pour him at least 10 ml / kg of crystalloid.
● Blood loss up to 800 ml is compensated by infusions of crystalloid solutions (sodium chloride
0.9%, Ringer's solution) in combination with colloids (HES - Gekodes, gekoton solutions; solutions
gelatin - volutens) with a total volume of 1200-1500 ml. In order to maintain hemodynamics often
250 ml of a 7.5% solution of sodium chloride are introduced, the introduction of a hypertonic solution of
NaCl is combined
with colloids or use complex Oncotic-hyperosmolar preparations (gecoton in
dose of 10 ml / kg per day), which give a powerful hemodynamic effect.
● Blood loss from 800 to 1000 ml is compensated by the introduction of crystalloid solutions in a dose of
10-12 ml /
kg and colloidal solutions of 5-6 ml / kg.
● Blood loss of 1000-1500 ml is compensated by infusions of not only crystalloid and colloid
solutions, but also blood transfusion.
● During infusion therapy, it is advisable to exceed the average amount of blood loss by
150-200%, and if necessary - 300%.
● The replacement of blood loss must be carried out under the control of the CVP. If during acceleration
infusion, he quickly increases and shortness of breath appears, this indicates the development of cardiac
insufficiency and dictates the need for the appointment of inotropic drugs: dopamine,
dobutamine.
Analgesics (with severe pain, an opioid, with mild - paracetamol, infulgan, analgin, ketans)
Anticoagulants (for the prevention of pulmonary embolism - fraxiparin, ciboc, Arikstra.)
Plasma substitutes (for the restoration of bcc 0.9% NaCl, Ringer's solution, rheosorbylact, SZP, drugs
blood)
Vascular preparations (to improve ICR - pentoxifylline, dipyridamole)
Decongestants (to reduce vascular tissue permeability-L lysine, attracts.)
The criteria for the adequacy of intensive care for traumatic shock are:
● AO
ser.
> 65 mmHg Art.,
● CVP> 7-8 mmHg. Art.
● diuresis> 0.5 ml / kg per hour,
● SpO
2
= 95-98%.
● the diagnosis is made on the basis of an X-ray examination in 2 projections, CT. (Visualization
bone fragments)
● After catheterization of the central vein, the level of central venous pressure (CVP) is determined and
take blood for research.
● Conduct laboratory tests (clinical blood test with the definition of the group, Rh
factor, coagulograms, biochemical studies, urinalysis).
Task57
A soldier with a burn of a flame of Sha-B-IV degree of the face, neck, front was delivered to the sorting
point
surface of the chest. The hair in the nostrils was burned, the mucous membrane of the lips, the tongue is
gray-white. Vote
hoarse, rapid breathing, shallow; "Tubal cough", which is accompanied by discharge
18arkotinnya with impurities of soot. In preparation for the evacuation, phenomena began to increas e
respiratory failure.
1.Install a preliminary diagnosis. Thermal burn, 18% superficial, 15% deep
burns, face, neck, front surface of the chest, respiratory tract Sha-B-IV steps. Optic shock
Ist.
Superficial-head and neck 9% + gk9% airway burn 15% deep burns.
2. Define emergency care tactics
1. Extinguish the flame, or remove the traumatic agent.
2. Relocation of the wounded to a safe area
3. Assess the condition and provide medical care according to the algorithm.
4. Cool the affected area. To do this, use a large amount of running water, or
cooling personnel anti-burn (hydrogel) dressings.
5. Remove clothing, ammunition, and all tightening items.
6. Cover the patient with a clean, dry sheet or thermal blanket to prevent further
pollution during transportation and temperature loss.
7. Provide vascular access. If possible, do this through non-baked skin, if necessary.
- through the burnt, securely attach the iv catheter.
8. Start the infusion using lactation Ringer's solution (LRE) or its analogues from the c alculation: with
body weight
60-80 kg - 300 ml / hour. With a body weight of more than 80 kg - for every additional 10 kg + 100 ml /
hour (so, at
the body weight of the victim 100 kg must be dripped 500 ml / hour).
9. Install a urinary catheter. It will help control diuresis. Due to the flood, we must
achieve an indicator of 1 ml / kg.
10. In case of damage to the respiratory tract to eliminate spasm of the bronchi and reduce swelling of the
laryngeal mucosa
- 150-200 mg of hydrocortisone or 60-90 mg of prednisolone, aminophylline are intramuscularly
administered,
antiallergic drugs.
11. In the nasal passages instill 10-12 drops of liquid paraffin. Increasing asphyxia due to edema
larynx is an indication for intubation or, if it is impossible, before conicotomy.
12. Perform adequate pain relief.
3. What drugs are used to treat? The amount of transfusion is determined by the formula
Parkland: 4 ml of liquid x patient body weight, (kg) x burned surface area, (%).
Depending on the area of burns, the required volume is from 3-4 to 10-14 liters. Total fluid volume
should not exceed 110-120 ml per 1 kg of body weight in adults, in children up to 140 ml is allowed.
The number of transfusion agents per day is calculated according to the Evans formula (3 ml × burn area ×
mass
body), but not more than 10-12% of body weight.
● Qualitative composition of transfusion agents and their ratio: - crystalloid solutions
(saline, disol, lactasol) - colloidal preparations (plasma, albumin,
polyglucin, reopoliglukin, gelatin, neocompensan) - salt-free preparations (5-10% solution
glucose with insulin, 0.1% novocaine, 0.85% NaCl solution).
● In the first 8 hours, half the daily amount of transfusion funds is administered. Ratio of components
transfusion drugs depends on the severity of the shock. In case of slight shock (Frank index - 30)
the ratio of colloidal, salt and salt-free is 0.5: 1: 1, with moderate severity (index
Franks 31-60) - 1: 1: 1, for severe (Franco index - 61-90) - 1.5: 1: 1, for extremely severe (index
Frank over 90) - 2: 1: 1.
● it is advisable to start anti-shock therapy with a balanced injection
electrolyte solutions (Acesol, Disol, Trisol, etc.). This ensures quick filling.
vascular bed, especially venous, adequate cardiac output, prevents spasm
vessels. After filling the vascular bed with electrolyte solutions, colloidal
plasma substitutes, because they contain fluid in the vascular bed, are rheological,
antiplatelet and detoxifying effect, reduce blood viscosity.
● The rate of administration of transfusion agents during the first hours after a burn is critical to
elimination of pathophysiological changes in shock. Fast recovery of vascular volume
the system eliminates vasospasm, reduces blood viscosity, acidosis, improves activity
myocardium.
● Simultaneously with transfusion therapy, normalizes the functioning of the heart and vascular tone
(corglucon,
strophanthin, dopamine, trental, chimes, etc.). To normalize metabolism, it is necessary
eliminate acidosis (sodium bicarbonate - 4.5% - 200-300 ml, lactasol, trisamine 200-300 ml),
carry out desensitization (diphenhydramine, suprastin, pipolfen), reduce proteolysis (trasilol,
kontrikal, gordoks), replenish energy reserves (glucose, vitamin C, B1, B6).
● Amplification of diuresis is carried out by osmodiuretics (10-15-20% mannitol solution), saluretics (2%
Lasix solution).
● Be sure to take into account the need for the introduction of corticosteroid hormones (prednisone up to
100 mg,
hydrocortisone 150-200 mg) due to acute adrenal insufficiency, and in oxygen therapy.
● To reduce hypercoagulation, blood viscosity and improve the rheological properties of blood are shown
the introduction of severe burn shock heparin 5 thousand. 5-6 times a day, antiplatelet agents (chimes,
2.0 ml three times a day, trental 0.5 ml twice a day), fraxiparin 3.0 ml twice a day or
FRAGMINE once a day.
● In order to reduce the phenomena of proteolysis, protease inhibitors, trasylol, contracal, and proudox are
administered up to 100
thousand units per day.
● In case of damage to the respiratory system, bronchodilators are administered to relieve bronchospasm -
2%
papaverine solution in a dose of 2 ml 3-4 times a day intramuscularly, 2.4% aminophylline solution - 10 ml
3-4
once a day, to suppress the secretion of the glands of the tracheob ronchial tree - 100-125 mg
hydrocortisone, lazolvan. Carry out oxygen therapy, inhalation of antitholytic enzymes and
antibiotics, bilateral vagosympathetic blockade according to A.A. Vishnevsky.
● 4. Interpretation of the results of an additional examination. Carry out laboratory research
(clinical blood test with the definition of the group, Rh factor, coagulograms, biochemical
studies, urinalysis).
Task58
Serviceman K., 27 years old, 1:00 ago received deep burns of both lower limbs. Are celebrated
oligoanuria (black urine with a strong odor), vomiting of coffee grounds, t - 35.6 ° С, intestinal paresis.
1. Formulate a clinical diagnosis. burn, 36% of deep burns, of both lower extremities Sha-B-IV
step. Optic shock Ist. ShK bleeding.
2. What is the burn surface area? 36% deep burns 18% 1 leg + 18% leg
3. What is the degree of burns you observe? Severe severe burn shock - occurs in patients with
deep burns ranging from 20.0 to 45.0% of the body surface. It develops during the first 2-3 hours.
Anuria can last up to 30 hours. Fatal outcome observed in 60.0%
4. Interpretation of the results of an additional examination. Carry out laboratory research
(clinical blood test with the definition of the group, Rh factor, coagulograms, biochemical
studies, urinalysis).
Task59
On the battlefield, the enemy used a chemical poisonous substance - mustard gas. Delivered to the BCH
a victim who, within 3:00 after exposure to mustard gas, had signs of poisoning: sensation
sand in the eyes, photophobia, lacrimation, sensation of dry throat, cough. When examining a military
paramedic discovered additional signs of poisoning: redness and swelling of the conjunctiva of the eyes,
hyperemia, swelling of the mucous membranes, lack of voice, fever, nausea, vomiting.
1. In what form mustard gas is used on the battlefield? aerosol
2. To which group of chemical warfare agents mustard gas belongs? organosulfur compound
chemical warfare agent. inhalation and contact poison
3. An oath of first aid in the medical center of the battalion. If drops of OM get on the skin or
clothing in the first 5 minutes is partially sanitized using IPP-8. In addition to personnel
means, solutions of 2% monochloramine, 5-10% iodine solution (for skin lesions) can be used
or wounds lewisite). After partial sanitization, the next 24 hours must be
full sanitization, that is, 6-7 times hygienic body wash with soap.
If OM enters the gastrointestinal tract with contaminated water or foo d, immediately induce vomiting and
the ability to thoroughly rinse the stomach and esophagus with a 0.02% manganese solution or water.
Detoxification therapy is especially indicated for mustard lesions. Performed by
intravenous infusion of 20 ml of 30% sodium thiosulfate solution, as well as canned blood or
blood substitutes.
With the phenomena of toxemia, oxygen therapy is prescribed; with violations of acid-base balance -
meadows;
with cardiovascular failure - cardiac glycosides, adrenaline preparations; during development
mustard anemia - transfusion of the nuclear fraction of the bone marrow and the introduction of vitamin
B12, ATP, folic
acids when attaching a secondary infection - antibiotics
4. Means of protection against mustard gas. The main protection against mustard gas, in particular the eyes,
face and
respiratory tract, is a gas mask. After getting on cotton clothes, mustard gas at 3:00
completely impregnates it, which may subsequently cause additional lesions. For
prevent contact with clothing and under clothing, use special protective
costumes.
For treating the skin (removing minor drops of mustard gas), clothing or items in contact with
mustard gas, oxidizing agents and chlorination agents (hypochlorites, bleach, chloroamides) are use d.
Task 60
A victim in a gas mask who complains about the general
weakness, headache, dizziness, dry mouth, nausea. According to the victim, these signs
appeared 2.5 hours 19 after a nuclear explosion, at the time of which he was in shelter.
Objectively: the face and neck skin are hyperemic, swollen, tremor of the fingers, body temperature
normal, pulse - 72 beats. / Min .., blood pressure - 105/60 mm Hg, heart and lungs without any changes,
stomach
stresses, stools are rare. Indicators of individual dosimeters - 3.8 gray.
1.Install a preliminary diagnosis. Acute radiation sickness marrow, intestinal, toxemic
form, 2nd (moderate) severity.
1gr = 100 rad, (380 tips for tasks) Radiation sickness of the 2nd (average) degree occurs with a total
exposure dose of 200 ... 400 r. The latent period lasts about 1 week. It appears in the form
severe malaise, nervous system disorders, headaches, dizziness, often vomiting
and diarrhea , fever, the number of white blood cells (especially lymphocytes) is reduced by 2 times.
Treatment lasts 1.5-2 months. Mortality - up to 20% of cases.
2. Identify emergency care tactics. according to clinical indications (relief of vomiting,
eliminate collapse, anesthesia, immobilization of damaged limbs) radiometric
biophysical research and situation analysis with an indicative dose assessment (issued
sanitary epidemiological station and is interpreted together with the general practitioner)
in case of radioactive contamination of the skin - decontamination, and in case of injury - the application of
an aseptic dressing on
areas of maximu m pollution; clinical examination of the victim with fixation of short data
survey and survey.
A comprehensive blood test is performed, including platelet and reticulocyte counts. Blood samples are
prepared
(5 ml in vitro with heparin) for counting aberration in a lymphocyte culture. Conduct biochemical
blood test for bilirubin, serum iron, CPK, amylase, transaminases and
sorbitol dehydrogenase.
Determine deoxycytidine and diastasis in the urine. Establish blood type and Rhesus affiliation.
3. What drugs are used to treat? In the phase of the primary reaction with nausea and vomiting
antiemetics are used (metoclopramide hydrochloride, atropine oxide, chlorpromazine). AT
in severe cases with constant vomiting and associated hypochloremia, an intravenous injection of s odium
solution is necessary
chloride, repeated injections of other antiemetics, and with a decrease in blood pressure - the introduction
rheopolyglucin or hemodesis in combination with mesatone or norepinephrine.
With the development of heart failure, korglikon, strophanthin are used. In the latent period at P.Kh. I-II
the severity of the patient should be in a hospital. During the height of the disease, bed rest is necessary.
regimen and maximum protection against exogenous infection.
Antibacterial therapy is carried out to the development of agranulocytosis, and when it is established
strict aseptic regimen. For the prevention of infectious complications prescribed antibacterial
drugs (oxacillin, ampicillin, biseptol, nystatin).
With hemorrhagic syndrome, drugs are used, make up for platelet deficiency, improve
coagulation properties of blood (dicinone, aminocaproic acid, amben), as well as local
action (hemostatic sponge, dry thrombin, fibrin film).
With the development of anemia, blood and red blood cell transfusions are indicated. To fight toxemia
used in / in the introduction of solutions of sodium chloride, glucose, hemodesis, polyglucin in combination
with
diuretics (furosemide, mannitol), especially with the threat of cerebral edema. Successfully apply
plasmapheresis.
In case of severe gastrointestinal damage, parenteral nutrition is prescribed using protein hydrolysates
fat emulsions.
In the first days after irradiation, antiproteolytic drugs (trasilol, contracal) are administered.
To normalize regional hemodynamics, improve microcirculation, Trental and Venoruton are prescribed.
solcoseryl. Apply hormonal ointments and ointments based on methyluracil. With the appearance of
hyperemia and
edema is recommended cold, lotions with a solution of rivano l.
4. Interpretation of laboratory examination results i. ARS I degree (mild) develops with
radiation exposure in a dose of 1-2 Gy. The primary reaction is absent or moderate, lasts somewhat
hours: there is no vomiting or it is disposable, appears no earlier than after 2-3 hours. after irradiation; may
be
slight muscle weakness, minor headache, body temperature is normal. Latent
period of 4-5 weeks. The number of lymphocytes from 3 days more than 1x109 / l, white blood cells 7-9
days more than Zh109 / l,
platelet count on the 20th day - more than 80x109 / l. Agranulocytosis, Infectious Complications, and
Clinical
bleeding usually is not present.
ARS of the II degree (average) develops when irradiated at a dose of 2-4 Gy. It is characterized by
pronounced
primary reaction, which lasts a day. Vomiting occurs after 1–2 hours, repeated; moderate muscle
weakness, moderate, but prolonged headache; body temperature subfebrile; insignificant
short-term hyperemia of the skin. The latent period lasts 3-4 weeks. The number of lymphocytes from 3
days 1-
0.5x109 / l, white blood cells on days 7-9 3-25x109 / l, platelets on the 20th day 79-50x109 / l.
ARS of the III degree (severe) occurs when irradiated at a dose of 4-6 Gy. After 30-40 minutes after
irradiation occur
repeated vomiting, severe muscle weakness, headache, low-grade fever, hyperemia
skin. The latent period lasts 1-2 weeks. The number of lymphocytes from 3 days 0.4-0.1x109 / l, white
blood cells at 7-9
day 1.9-0.5x109 / l, platelets on day 20 less than 50x109 / l. In the midst: infectious
necrotic complications (sepsis, pneumonia, necrotic tonsillitis), multiple hemorrhages
under the skin, mucous membranes, nasal, intestinal, uterine bleeding, toxic-septic, hemorrhagic
enterocolitis; agranulocytosis, anemia, thrombocytopenia, depletion of bone marrow.
ARS of the IV degree (extremely severe) is observed with radiation exposure at a dose of 6-10
Gy. Vomiting occurs
directly or after 5-20 minutes. after irradiation, is continuous, muscle weakness
reaches degree 42 of adynamia, pronounced constant headache, dizziness, sometimes
confusion. Persistent hyperemia of the skin, body temperature increased to 38-39 ° C. Latent period
absent or lasts 3-4 days. The number of lymphocytes from 3 days is less than 0.1x109 / l of leukocytes for
7-9 days
less than 0.5x109 / l. During the height of the spread of infectious necrotic complications, signs
deep intoxication, gastrointestinal disorders.

Surgery Station 1-4

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Station 1

Abdominal Surgery Clinical task

1 A 35-year-old patient was taken by an ambulance with complaints of general weakness,

1. Peptic ulcer of the duodenum. Acute gastrointestinal bleeding.

1. Cancer is a stomach ulcer. Acute gastrointestinal bleeding. Hemorrhagic shock II

1. Peptic ulcer of the duodenum. Acute gastrointestinal bleeding.

1) Traumatic lesion of the parenchymal organ (liver).

Surgery draınıng wıth ct or ultrasound wıth guıdance

Treatment antıboıtıcs broad spectrum

Diagnosis Polytrauma Gastrointestinal perforation Open craniocerebral trauma subcutaneous

1. Crohn's disease, ileocolitis with damage to the terminal ileum, chronic

1) Acute subcutaneous paraproctitis

1) Chronic paraproctitis. external fistula

4) Acute hemorrhoids. Hemorrhoidal Thrombosis

Polyps of the lower ampulla of the rectum

1 - Diagnosis: Acute anal fissure

1. - Diagnosis: Complete prolapse of the rectum.

Diagnosis: suppuration of the epithelial coccygeal passage (pilonidal cyst)

Diagnosis: Perforated gastric ulcer / duodenum. Pneumoperitoneum?

1) Diagnosis: Peptic ulcer complicated by perforation.

Diagnosis: Acute pancreatitis, moderate, uncomplicated.

Diagnosis: Acute Biliary Pancreatitis

1) Diagnosis: Acute destructive pancreatitis, abscess (possibly pseudocyst) of the pancreas

1. DIAGNOSIS: chronic cholecystitis in the acute stage

DIAGNOSIS: chronic stoneless cholecystitis, recurrent course, acute phase.

Diagnosis: gallstone disease, clinical stage: calculous cholecystitis,

Pancreatic head cancer complicated by obstructive jaundice

1. DIAGNOSIS: Acute appendicitis uncomplicated

1. DIAGNOSIS: Appendicular infiltrate

Diagnosis: Acute appendicitis (gangrenous?). Complications: perforation of the appendix

Diagnosis: Constrained right-sided inguinal hernia. Complications: intestinal gangrene,

1) Diagnosis - Infringement of a right-sided inguinal-calico-hernia (oblique, because it goes

1) Diagnosis - impaired right-sided inguinal-Kalitkov hernia

Diagnosis: diverticulosis complicated by bleeding.

Diagnosis: Diverticulosis disease complicated by paracolic infiltrate

Diagnosis: neoplasms of the rectum (most likely malignant neoplasm)

Diagnosis : Stage 4 sigmoid cancer with liver metastases.

Diagnosis: chronic pancreatitis, stage of exacerbation, post-necrotic cyst of the head p / s,

1. Diagnosis - Pyloroduodenal stenosis, stage of compensation

1. Diagnosis of pyloroduodenal stenosis, stage of subcompensation

Diagnosis: cirrhosis of the liver of alcoholic etiology, with moderate activity,

1) Diagnosis - post-traumatic rupture of the spleen

Diagnosis: Intestinal obstruction obstruction (possibly due to gallstone obstruction)

Diagnosis: moderate dumping syndrome

Diagnosis: Acute small bowel obstruction.

1) what is the diagnosis?

a) what is the diagnosis?

1. What is the diagnosis?

1. What is the diagnosis?

1) establish a clinical diagnosis.

1) establish a clinical syndrome.

1) Establish a clinical diagnosis.

1) Establish a clinical diagnosis.

1. Establish a clinical diagnosis.

1. Establish a clinical diagnosis

1. Establish a clinical diagnosis

1) what diagnosis can be suspected.

1) What diagnosis could the doctor suspect?

1) What is the doctor’s tactics?

1) What diagnosis was suspected?