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Лікування даного хворого (з випискою рецептів та обгрунтуванням)
Включає комплекс туберкуло статичних й інших препаратів, терапевтичних і хірургічних заходів, які слід застосовувати від початку курації студентами до повного виліковуванні хворого згідно установлених схем з врахуванням особливостей клініки та перебігу захворювання, лікування, застосованого до початку курації студентом, чутливості МБТ до туберкулостатиків. В лікування також слід включити гігієно-дієтичний режим, засоби симптоматичної терапії, терапію ускладнень туберкульозного процесу та супутніх захворювань.
Щоденники.
(за час спостереження з відображенням динаміки в лікуванні)
Схема написання щоденника.
Дата, температура, частота дихання і серцевих скорочень, маса тіла. Оцінка стану хворого (з обгрунтуванням), динаміка скарг, відновлення апетиту, сну тощо. Динаміка об’єктивних показників стану внутрішніх органів. Характеристика фізіологічних випорожнень. Динаміка в лікуванні хворого.
Епікриз.
(Схема епікризу при виписці)
Основні відомості про хворого, дата поступлення, на який день хвороби, в якому стані, з якими ведучими скаргами чи синдромами. Обгрунтування клінічного діагнозу (основного, ускладнень, супутнього). Проведене обстеження. Проведене лікування. Особливості перебігу захворювання у даного хворого. Стан при виписці (покращення, видужання, погіршення). Дата виписки. Рекомендації.
Прогноз
Вказується прогноз відносно життя і виліковування пацієнта, стійкої чи тимчасової втрати працездатності, групи інвалідності
Підпис куратора
Scheme clinical examination of the patient and execution history of Phthisiology
Department of Tuberculosis and Pulmonology of the rate of occupational diseases
Head of Department prof. __________________________________
MEDICAL card of patient
Patient________________________________________________________________
(Surname, first name, middle name)
Clinical diagnosis: ________________________________________________________
(Clinical form, localization)
_______________________________________________________________________
(Segments, phase process, bacteria)
Curator: student________course___________group___________________faculty
______________________________________________________________________
(Surname, first name, middle name)
Date: beginning of curatio__________________end of curatio_______________________
BACKGROUND
Passport part
Surname, name, patronymic
Age (date of birth)
Social conditions
Profession
Education
Job
Post
Home address
Start Date of Supervision
Diagnosis at admission
Full clinical diagnosis
Persons who are in contact with the patient
Complaints
On the day of Supervision: count complaint specific to the disease, as well as those which reflect the complications and comorbidities background.
1. Complaints of Respiratory: choking cough, sputum, chest pain, hemoptysis.
2. Tuberculosis intoxication: fatigue, weakness, drowsiness, loss of appetite, low-grade fever, sweating
3. Cardiovascular system. Heartbeat, edema, heart pain, heart disruptions.
4. Digestive Tract. Smack in the mouth, heartburn, excessive salivation, dryness, thirst, dyspepsia, abdominal pain.
5. Urinary reproductive system. Pain during urination and irradiation. Spontaneous urination. Pain during menstruation and their characteristics.
6. Bodies movement. Pain in the extremities, muscle and joint swelling.
7. Nervous System. Sleep, memory, fatigue during walking, headache, dizziness, seizures, symptoms of brain damage, peripheral nerves.
Anamnesis life
Enquiry about the patient's life begins with birth, place of residence and that the family environment in which he grew up and developed.
Childhood: birth in term or premature, how the account. Breast fed mother or artificially. Do not rickets.
Childhood and school years: living conditions (flat close, cold, damp and dry), terrain, food (How many times a day, the nature of food quality), health and development (not behind it from peers) are studied, easy or difficult to learn, overall development and early maturation.
Professional history: what, where, how long worked in conditions that no occupational hazards. Working conditions at this time (duration, mental or physical work, the state of the working space, etc.). Are there conflicts at work. How to use weekends and holidays.
Marital status. Composition of family . Age of each member of family. Material conditions. Diet.
Bad habits: smoking (of which and how many years of smoking cigarettes, or cigarettes per day), alcohol consumption (frequency, quantity), drug use, medications (What).
Postponed disease list in chronological order, starting from childhood. Pay particular attention to infections: tuberculosis, influenza, scarlet fever, typhoid, dysentery, allergies, neuro-psychiatric injury, poisoning and helminth infestation. Ask about venereal disease, hypertension, diabetes, body mass.
Contact bacillary patients. Time and duration, nature of contact, clinical form of tuberculosis bacilli and massive selection of patient contact
For women beginning menstruation, their nature and the cycle, pregnancy, childbirth (in term or premature, stillborn or not), abortion (or no complications). The death of children, the age at which the cause. Menopause proceeded calmly, painfully. Heredity: health of father, mother, brothers and sisters. Health status of spouse, children, parents. If you died, indicate age and reason. With diseases among relatives pay special attention to tuberculosis, malignant neoplasms, diseases of the cardiovascular system, alcoholism, syphilis, mental illness, diabetes, obesity.
History of the disease
Objective: To obtain information about the sequence of appearance of the full range of symptoms to address the issue of diagnosis of the disease is already in the initial period.
Duration of illness (date and possibly hour days onset to assess its duration). The first symptoms of the disease and their dynamics before the major symptoms (strengthening, weakening, change character) to assess the onset of the disease (acute, subacute or gradual). Possible cause of the disease according to the patient.
Date of tuberculosis. Who diagnosed. The clinical form of the disease. Other ways of detecting TBC observed, where the patient was treated. Conducted treatment and its effect. Manifestations of the disease during the height of the speaker and on the background of the treatment (before admission and during his stay in the hospital at the beginning of Supervision).
Date of first detection of mycobacteria in sputum and the results of further studies on the MBT. Whether conducted fluorography and Mantoux test
Objective SURVEY
The patient's condition (satisfactory, moderate, severe, very severe).
Provisions in bed (active, passive, involuntary).
The behavior of the patient (adequate, inadequate).
The consciousness of the patient (gums, dizziness, absent). In the absence of consciousness assess the degree of coma (see examination of the nervous system).
Body (ratio of height and lateral body size, symmetry and proportionality of body parts, the type ofconstitution).
Condition of skin and visible mucous membranes:
Color: red, cyanotic, pink, pale pink, marked pallor, yellow (colors: saffron, earthy, lemon) or smuhlyaste color. Discoloration in some areas (nasolabial triangle nose, earlobes, legs) in natural folds, on the cheeks, nose, around the eyes (peryorbital). The rash, if any, need to fully characterize because their character is an important examination of the patient. Eruptions on the skin (exanthema): Sensitivity of the skin (temperature, pain, tactile). Having developed venous grid showing localization.
Evaluation of hair: the development and growth of hair, presence of local or total baldness, development of eyebrows and eyelashes elasticity. The presence or absence of light
Determining the type demographism (red, white, mixed), its rate of appearance and disappearance.
Subcutaneous fat layer: uniformity of distribution, thickness of subcutaneous fat folds in some areas of the body. Lymphatic system: localization of lymph nodes visualized (single or multiple) when viewed with the assessment of changes in the skin, subcutaneous tissue over them and the surface of the site and that showing their location (occipital, posterior and anterior cervical, BTE, submandibular pidboridni, over-and subclavian, inguinal, elbow, inguinal. popliteal). Condition skeletal system. Condition of joints.
Cardiovascular system.
Review area of the heart: overemphasizing the area of the heart ("cardiac hill"). Apical impulse - its location, characteristics (strong, weak, limited, diffuse, regular, irregular). Negative apical impulse. Visible pulsation elsewhere chest throbbing epigastrium.
Auscultation of the heart:
Cardiac - loud, quiet, clear, deaf, clear, unclean. Gain (accentuation) tones, easing. Splitting, split tones gallop. Pendular rhythm embriokardiya. Noises heart. The strength and nature of noise (strong, weak, soft, rough, hard, blowing, other shades). Noise ratio of the individual phases of the heart (systolic, diastolic, presystolic, protodiastolic, mezodiastolic). Pulse - the number of beats per minute
Respiratory system.
Breathing through the nose: free, complete inability to breath through the nose, through one or both nostrils. Respiratory rate per minute. Change in respiratory rate (at rest the patient) - rapid breathing, excessively rapid breathing (polypnoe, tachypnoe), slowed breathing (bradypnol, oligopnoe). Character breath - calm, free, difficult (dyspnea). Dyspnea (dyspnoe) - inspiratory, expiratory, mixed. Participation auxiliary muscles. Attacks of breathlessness.
Cough - dry, with the release of phlegm; loud, hoarse, silent, barking strong, weak (coughing), paroxysmal, regular, frequent, loose.
Voice tremor strengthened, weakened, there is no where to find.
Comparative percussion (quiet, direct) for symmetric locations tops, front, side and rear surfaces of the lungs. Features percussion: the power of sound - loud, dull, dull, nature sound - clear lung, tympanic, boxes, metal, cracked-pot sound. Boundary amended lung sounds, change these limits depending on body position.
Topographic percussion - defining the boundaries of the lungs in parasternal, nipple, inguinal, scapular and paravertebral lines.
Auscultation of the lungs. The nature of breathing (puerylne, vesicular, weakened, bronchial, amphoryc, hard, intermittent, vague). The weakening of respiratory sounds in both lungs. Lack of respiratory sounds in one lung. Rattling (ronchi) - dry, wet, large, medium and fine; crepitation, subcrepitation, resonant noteless. Number wheezing - many poorly, are rare. In what areas of the lungs auscultated wheezing. Do auscultated wheezing while inhaling, exhaling continuously. Does the auscultatory pattern after coughing. Pleural rub. Splashing sound. Bronhofoniya, listening to whispered speech. The sound of falling drops.
Digestive system.
Inspection of the abdomen. Form abdomen: normal configuration, enlarged, drawn.
Superficial palpation of the abdomen just for general guidance: increased sensitivity (zone Zakharyin-Ged) in different areas. Having hernial openings hernial vyp'yachuvan.
Deep palpation of the abdomen for Obraztsov-Strazhesko (methodical deep sliding palpation: sigmoid, descending, transversum, ascending colon, stomach). Splashing sound in the stomach. Definition of the lower boundary of the stomach.
Palpation of the liver. Characterization lower edge: sharp, rounded, smooth, with clippings, hard, soft. The surface of the liver - smooth, rough, bumpy. Consistency - hard and soft.
Tenderness liver - diffuse, limited mobility of the liver.
Palpation areas of gull bladder resistance, abdominal wall pain. Symptom Ortner.
Palpation of the spleen - the position of the patient on the right side. Properties of the front edge (sharp, rounded, smooth, with clippings, hard, soft). The surface of the spleen - smooth, rough, bumpy. Consistency - hard, soft, elastic. Pain spleen palpation.
Percussion of the abdomen. Tympanic sound goofy localization.
Urogenital.
Review lumbar - redness, swelling of skin, swelling, overemphasizing - right, left. Pasternatsky.
Palpation of kidneys - bimanual in the supine position, pain. If kidney propalpovuyutsya then determine their shape, size, surface, pain, mobility.
Nervous System.
Consciousness. Emotional mood (positive, negative).
Sensitivity (pain, temperature, tactile). The autonomic nervous system: dermographism (red, white, diffuse, edematous, appears fast or slow time).
Tuberculin. Result of Mantoux test with 2 MCA-L
X-ray examination
Decryption radiographs conducted as follows:
1. Quality x-ray.
2. The patient behind the screen
3. Overview of the soft tissues of the chest. Shades of soft tissue lesions should be distinguished from infiltrations.
4. Depth slices and character lines smearing (in tomograms).
5. Review skeleton chest. Determine its status and relationship with the shadow picture of the lung fields and mediastinal shadows.
6. Review diaphragm, pleural leaves. Estimated ratio of shade to diaphragm and pleural shadows paintings lung fields and mediastinal shadows.
7. Review mediastinal shadow. Form size and position relative to the vertebral trunk.
8. Overview of the roots of the lungs. A differential diagnosis between petrificates lymph nodes and cross sections of vessels.
9. Review lung fields. The presence or absence of pulmonary picture of his characteristics.
10. Characterization revealed pathological changes in the lung: a) location, b) the value, c) homogeneity, d) intensity, e) form and crisp contours.
These laboratory studies
1. Complete blood count, urinalysis.
2. Determination of blood group and Rh factor
3. Wasserman reaction
4. Definition of AIDS virus infection
5. Biochemical analysis of blood
6. Research sputum and bronchial washing water for MBT by microscopy. Flotation, fluorescent microscopy, culture.
7. Antibioticgrammy
8. The degree of inactivation of drugs Ginko
9. Litter on worm eggs
10. Mantoux test
11. Sample Koch
12. Research micronutrient metal enzymes.
13. Immunological studies
Functional methods.
1. Spirography
2. ECG
3. Bronchoscopy
4. Diagnostic puncture
5. Pneumatic
Preliminary diagnosis and its rationale.
Due to complaints (list of complaints), history of illness (early, the course, the dynamics symptoms last exacerbation), life history (spryayuchi factors), epidemiological history (data or instructions of a possible contact the local epidemiological situation), rejecting an objective examination of the patient are the following leading symptoms. and put a preliminary diagnosis
Advanced diagnosis, comprising:
a) clinical forms of the disease
b) the localization process
c) phase of development
d) Bacillus allocation
e) complications
e) comorbidities
Differential diagnosis
Given the symptoms of the underlying disease, their dynamics and the results of additional tests. Necessary to exclude clinically similar diseases with mandatory comparison with the clinic of patient. In diseases with severe clinical recurrence differential diagnosis is made according to the sequence of periods of illness.
Tuberculous bronhoadenit - measles, whooping cough, influenza, sarcoidosis, lymphoma leukemia, Hodgkin, lymphoma, cancer.
PTC - pneumonia, sarcoidosis, lymphoma leukemia, Hodgkin, lymphoma, cancer, metastasis to lymph nodes.
Subacute and chronic disseminated TBC - finely lobular pneumonia, disseminated cancer, syphilis lung, pneumoconiosis, fibrosis.
Focal TBC - pneumonia, rheumatoid lung granuloma
Infiltrative TBC - pneumonia, eosinophilic infiltration, peripheral carcinoma, sarcoma, atelectasis, Hodgkin, parasitic cyst, dust fibrosis.
TBC infiltrate the collapse - lung abscess, actinomycosis, unfilled cyst lung bronchiectasis.
Tubercle - pneumonia, tumors, Echinococcus, swelling of the collapse, encysted pleurisy
Cavernous and fibrocavernous TBC - Bullous emphysema, abscess, cyst, pneumothorax.
Cirrhotic TBC - atelectasis lung fibrosis, cirrhosis, sarcoidosis, pneumoconiosis.
Final diagnosis.
Rationale diagnosis begins with a medical history, objective examination, and laboratory parameters used other methods of examination of a sick child. In the presence of comorbidities should give a brief justification for each of them.
Treatment of the patient (with the writing prescriptions and rationale)
Includes tubercle complex static and other drugs, therapeutic and surgical measures to be applied from the beginning of Supervision students to complete cure of the patient according to established schemes with regard to clinical features and course of the disease, the treatment applied to the student of Supervision, the Office of sensitivity to tuberkulostatykiv. In the treatment should also include hygiene-dietetic treatment facilities symptomatic treatment of complications of therapy of tuberculosis and related diseases.
Blogs.
(During the observation of reflection dynamics in treatment)
Scheme of writing diary.
Date, temperature, respiratory rate and heart rate, body weight. Assessment of the patient (with justification), the dynamics of complaints, restore appetite, sleep and so on. Dynamics of objective indicators of the internal organs. Characterization of the physiological stool. Dynamics in the treatment of the patient.
Epicrisis.
(Scheme Epicrisis at discharge)
Basic information about the patient, date of admission on the day of the disease, the condition with which the leading complaints or syndromes. Rationale for clinical diagnosis (primary, complications, concomitant). Examined. Treatment. Features of the disease in this patient. Condition at discharge (improvement, recovery, deterioration). Date of discharge. Recommendation.
Forecast
Specifies prediction concerning life and cure the patient, persistent or temporary disability, the disability group
Signed curator