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

In most cases, after a disease or an operation, patients should know about an important stage - recovery (rehabilitation) after injuries and/or fractures. After all, prolonged immobility of a damaged or diseased part of the body, the absence of habitual loads, vascular and other changes lead to muscle atrophy and limited joint mobility. More than half of the success of treatment after injuries depends not only on the quality of the operation, but also on the well-conducted post-traumatic rehabilitation. A fused fracture, reduced dislocation, does not always mean recovery.

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

Rehabilitation after injuries. What is it like?

Among the main types of rehabilitation after injuries, one can single out physiotherapy exercises (exercise therapy), massage, mechanotherapy and physiotherapy.

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

Mechanotherapy is used to develop muscle strength, improve coordination of movements and form the correct motor stereotype. One of the types of mechanotherapy is CPM-therapy - a modern method of treating injuries that allows you to restore joint mobility through "passive action".

PREVIOUS DISEASES, INJURIES

He suffered from rubella, chicken pox. Viral hepatitis, tuberculosis, syphilis, AIDS denies. No blood transfusions were performed.

In 2009, a pulmonectomy of the right lung was performed for central cancer.

Relatives did not have respiratory diseases

ANAMNESIS VITAE

Secondary special education, specialty gas-electric welder. Served in the army for 2 years. She has been smoking 2 packs a day since adolescence, abused alcohol, after suffering a right-sided lung pulmonectomy for central cancer, she tries not to drink alcohol. Index pack/years 20*46/20= 46 pack/years

Allergic reactions are denied.

DATA OF PHYSICAL AND INSTRUMENTAL RESEARCH METHODS

1. Outdoor study

General inspection

General condition of moderate severity

The position of the patient is active

Consciousness is clear

Normal facial expression

The physique is correct, asthenic constitutional type, height 165, body weight 48 kg, temperature 37.1 o C.

Skin normal color, elasticity is reduced, the degree of humidity is normal, no rash, no varicose veins, no rash, male hair type, no hemorrhages.

mucous membranes pale pink, no rash, no plaque on the tongue, no plaque on the tonsils, pale pink pharynx.

Subcutaneous adipose tissue moderately developed, no edema

The lymph nodes submandibular, cervical, occipital nodes are palpable, not enlarged in size, soft and homogeneous in consistency, not soldered to the surrounding tissue and to each other, there is no pain on palpation.

muscles the muscular system is developed according to age, muscle strength is moderate, there is no tremor, there is no pain on palpation, the tone is normal

Bones no deformity or pain

joints the configuration is normal, there is no hyperemia of the skin and local temperature increase in the joint area, the movements are active, free.

2. Study of the nervous system and sense organs

Consciousness is clear, oriented in place and time, emotionally stable, memory is preserved, sleep is not disturbed, there is no irritability and increased fatigue.

Pain, tactile, and temperature sensitivity are pronounced, smell and taste are preserved, visual acuity is preserved, the palpebral fissures are uniform, there is no strabismus, the size of the pupils is symmetrical, their shape is round, accommodation and convergence are not impaired, hearing is good, speech is not impaired, coordination of movements is good.

3. Examination of the respiratory system

Breathing through the nose is free, there is no feeling of dryness in the nose, no discharge from the nasal passages is observed, there are no nosebleeds, the sense of smell is preserved. Pain at the back and root of the nose, in the area of ​​the frontal and maxillary sinuses were not noted. Persistent unproductive cough with viscous mucous sputum. The cough is aggravated by physical exertion, eating. Expiratory dyspnea when ascending to the 3rd floor.

The chest is barrel-shaped, symmetrical, auxiliary muscles participate in the act of breathing, the intercostal spaces are dilated, breathing is noisy, respiratory rate 21.

Palpation of the chest: Elasticity and resistance are reduced, there is no pain, vocal trembling on the left is weakened.

Percussion of the chest;

• A) Comparative percussion: boxed percussion tone on the left.
• B) Topographic percussion: Lower borders of the lungs:

topographic line	Right lung	Left lung
Parasternal		along the lower edge of the IV rib
midclavicular		along the 7th rib
anterior axillary		along the 8th rib
Middle axillary		along the IX rib
Posterior axillary		along the X edge
scapular		along the 11th rib
Perivertebral		spinous process of thoracic vertebra XII

The height of the tops of the lungs:

Mobility of the lower lung edges:

right no

left 3-4-3

Auscultation of the lungs there is no breathing on the right, hard breathing on the right.

4. Study of the cardiovascular system

There is no protrusion in the region of the heart, there is no visible pulsation, the left ventricular beat is palpated in the 5th intercostal space 1 cm medially from the left mid-clavicular line, the right ventricular beat is not palpable, there is no heart trembling, there is no pericardial friction noise.

Percussion of the heart

Limits of relative cardiac dullness

Auscultation of the heart

Heart sounds are muffled, there are no noises, the rhythm is correct, heart rate is 72, blood pressure is 90/60 mm RT st.

5. Examination of the digestive system

The tongue is moist, pink, without plaque.

Abdominal examination: rounded configuration, no flatulence, satisfactory condition of the umbilicus, veins not dilated, no hernias, abdominal circumference 100 cm, no visible peristalsis, superficial palpation of the abdomen is soft and painless, pain points are painless, symptoms of Ortner, Kerr, Frenicus, Crovoisier are negative. Data of deep palpation: the lower border of the stomach is 2 cm above the navel, palpation of the intestine - no features. Abdominal percussion data: no fluid. Auscultation of the stomach and intestines: auscultation is quiet.

6. Study of the hepatolienal system

Liver on palpation along the edge of the costal arch, dimensions according to Kurlov 9-8-7. The gallbladder is not palpable, soreness in pain points is not established. The spleen is not palpable.

7. Examination of the urinary system

On examination, the renal region was not changed, the kidneys were not palpated, they were painless on palpation, Pasternatsky's symptom was negative on both sides.

8. Endocrine system

The thyroid gland is not enlarged, eye symptoms are negative, secondary sexual characteristics correspond to sex and age.

I stage of differential diagnostic search

Leading syndrome: bronchial obstruction

1) Identification method:

The diagnosis of severe COPD in the exacerbation phase was made on the basis of complaints of experiential dyspnea, persistent unproductive cough with viscous mucous sputum, based on the anamnesis: smoking since adolescence, pack/year index 46 - very high risk; on the basis of physical examination: emphysematous form of the chest, participation in the act of breathing of auxiliary muscles; percussion tone is boxy, the borders of the lung are lowered, the mobility of the lower edge is limited, on auscultation: breathing is hard.

2) Exclusion method:

Syndrome of bronchial obstruction can be with the following diseases:

• · lung cancer
• · bronchial asthma
• · acute bronchitis

There are no signs of cancer such as cough with blood, chest pain, hoarseness, pleural effusion.

There are no signs of bronchial asthma, as there is no aggravated allergic history, there are no asthma attacks, there are no wet rales and crepitus on auscultation.

There are no signs of acute bronchitis as an acute onset without a history of the disease, no wet cough, pallor, high humidity skin integument, cyanosis of mucous membranes, chest of the correct form, normal voice trembling, dry buzzing and whistling rales, moist small bubbling rales, tachycardia.

Additional research methods are needed to exclude the diagnoses of lung cancer and bronchial asthma.

Introduction

What is rehabilitation

“A good doctor does not heal a person, but helps a person to be cured,” the ancients said. But this truth is sometimes, to our common regret, forgotten by modern practitioners. Meanwhile, restorative medicine as a "science to resurrect" has existed for many centuries, helping to mobilize the body's hidden resources and activate its defense mechanisms. Thanks to gentle and pill-free methods of restorative (or rehabilitation - in the modern interpretation of the term) therapy, the human body, like a phoenix bird, rises from the ashes of losses, independently coping with illnesses and misfortunes: restores damaged tissues, returns diseased organs to normal functioning, splices bones ... In many cases, restorative medicine is more attractive to the suffering person than conventional medicine. And how could it be otherwise? After all, positive results are literally evident, and Negative consequences are practically absent, which cannot be said about the majority of chemical pharmaceuticals taken from the arsenal of official medicine. And time, precious time! Long-term practice of healing shows that the recovery period is significantly reduced, it is only necessary to apply one of the many methods of restorative medicine that suits the case.

What can rehabilitation medicine offer you? In what healing circle will an experienced rehabilitation doctor lead the patient (there is such a rare specialization in official medicine)? The basic methods used in restorative medicine are as old as our world. These traditionally include:

body cleansing. For example, bowel cleansing with hydrocolonotherapy (the famous "Hollywood diet"), blood plasmaphoresis, cleansing with medicinal herbs. Often such a cleansing is the first step to restore and improve the body;

hydrotherapy, or therapeutic baths and irrigation, such as mineral, turpentine, aromatic, hydrochloric, carbonic and others, as well as a sauna and bath, aqua-physical culture, therapeutic courses of mineral waters. Specially selected and prepared liquids wash and saturate tissues with nutrients, help restore the disturbed balance of substances and microelements in the body, treat many diseases - from gastrointestinal and to seemingly intractable female problems, not to mention the fact that they rejuvenate and lead to the desired tone. not only the body, but also the thoughts;

physiotherapy: electrophoresis, iontophoresis, phonophoresis, laser therapy, ultrasound therapy, magnetotherapy, myostimulation, vacuum therapy and so on. All of us at least once in our lives, but visited the physiotherapy department of the district clinic, and there is no need to list here all the available miracles of recuperation: activation of the defense system, metabolism, blood and lymph flow, accelerating regeneration and increasing the overall tone of organs and tissues;

hirudotherapy, or treatment with leeches;

reflexology, or impact on the active points of the human body, activating internal resources;

balneotherapy, or mud therapy;

Numerous therapeutic and restorative massage techniques;

herbal medicine, or herbal treatment, and much, much more.

Consult a doctor, choose a set of procedures for yourself and start working on restoring your health. And do not listen to those who will say that restorative medicine is akin to shamanism, or equate it with alternative medicine. Rehabilitation medicine is a serious direction in modern medical science and has nothing to do with unscientific and unreliable "grandmother's methods". Restorative medicine using advances modern science, advanced methods for studying the natural capabilities of a person, develops scientifically based techniques and technologies that contribute to the disclosure of the dormant resources of our body, which leads to the improvement of the functioning of all organs and systems, and not only those affected by the disease. And this is serious. All these methods act gently, excluding the paradox of the chemotherapeutic effect, when "we treat one thing and cripple the other." Restorative therapy is based on a simple postulate: Human body is able to independently cope with almost any disease, you just need not to interfere with him, but to help. Rehabilitation therapy and helps him in this. Rehabilitation is now commonly understood as a system of complex measures of a medical, psychological and social nature, aimed at improving a person's adaptation to the requirements Everyday life, workloads. When is her healing support available?

Restorative medicine is appropriate for a very wide range of diseases and injuries. Here is an approximate, and therefore incomplete list of branches of official medicine where its methods are successfully applied: cardiology, neurosurgery, treatment of diseases of the male and female urogenital spheres, obstetrics, endocrinology, treatment of diseases of the gastrointestinal tract, nephrology, pulmonology, traumatology and surgery, treatment neurological diseases and psychiatry, otorhinolaryngology (ear, throat, nose), arthrology and orthopedics, dermatology. After major operations or conservative treatments that require serious intervention in the body, restorative medicine provides quick rehabilitation and helps complete recovery, and in milder cases, you can often do without the help of pills, injections and droppers, and even without the direct intervention of a surgeon.

When is rehabilitation required? As a rule, rehabilitation is needed for patients recovering from an acute illness, injury or surgery, people suffering from chronic diseases, and just those who are exposed to great physical and psycho-emotional stress at work or in everyday life. Moreover, the more serious and severe the disease, injury, surgery, the longer and more difficult the recovery.

Diseases that require rehabilitation:

Vegetovascular dystonia;

Ischemic heart disease, including acute myocardial infarction, condition after coronary bypass surgery;

Hypertonic disease;

Chronic forms of vascular diseases of the brain;

Condition after a stroke;

Chronical bronchitis;

Bronchial asthma;

Chronic gastritis;

Peptic ulcer of the stomach and / or duodenum;

chronic colitis;

Irritable bowel syndrome;

Urolithiasis disease;

chronic hepatitis;

Cirrhosis of the liver;

Chronic pancreatitis;

Diabetes;

Thyroid diseases;

Chronic pyelonephritis;

Diseases of the spine and peripheral nervous system;

Joint diseases;

Diseases of the vessels of the extremities (obliterating atherosclerosis, obliterating endarteritis);

Diseases of the prostate gland;

Breathing disorders during sleep (snoring, sleep apnea);

Insomnia;

Overwork;

chronic fatigue syndrome;

Obesity and many others.

Naturally, in our book we will not be able to consider all of the listed cases, so we will focus on the most, if I may say so, popular ones. Moreover, such an approach is justified by considerations of your safety: each specific case must be considered by a specialist in rehabilitation medicine, and the more severe the condition of a particular patient, the more thorough the medical approach to him should be.

This text is an introductory piece.

Next, the patient should be asked to tell about all the illnesses, injuries and surgical operations they have had. This will help eliminate some diseases. For example, if a patient has had an appendectomy (surgical removal of the appendix) in the past, then pain in the lower right abdomen cannot be a manifestation of acute appendicitis. On the other hand, knowledge of previous illnesses helps to detect relapse. If a patient was hospitalized in the past due to duodenal ulcer, and now he complains of burning pain in the upper abdomen, subsiding after taking antacids and milk, then it can be concluded with almost complete certainty that this pain is due to an exacerbation of peptic ulcer. One should be aware of those diseases that were previously diagnosed in this patient, such as diabetes mellitus and hypertension, as they can become aggravated by a new disease, and can also cause its complications. The patient needs to find out if he is allergic to any drugs and whether he was ill from any drugs.

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Overview of body systems

In cases where the diagnosis is not clear or complete and there is time, it may be useful general review various systems body and search for relevant symptoms.

Head - Past trauma (wounds), severe headaches.

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

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

Nose - Bleeding, runny or stuffy nose.

Mouth - Ulcers, pain, difficulty swallowing.

Neck - Muscle stiffness, swollen lymph nodes, soreness.

Respiratory system - Cough and sputum pattern, coughing up blood, chest pain when breathing, shortness of breath.

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

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

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

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

Family and social history - The patient should be asked if other members of his family had diabetes, tuberculosis, heart disease, cancer, or other diseases, signs of which may be observed in the patient himself.

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

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Physical examination

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

A physical examination requires a stopwatch or clock with a second hand, a blood pressure monitor, a stethoscope, and a thermometer; examination should be carried out in a quiet room.

Respiration pulse and temperature

What is the respiratory rate? What is the pulse rate? What is the body temperature?

General form

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

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

Are there signs of injury such as cuts, abrasions, swelling?

Are there signs of jaundice or inflammation of the sclera (the white part of the eyeball)? (Signs of jaundice are best looked for when sunlight; under artificial light, many healthy people have a yellowish sclera.)

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

Look for any bleeding or unusual discharge from the nose.

Mouth and throat

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

Ask the patient to lie on his back and put your hand under his head. Ask the patient to relax, while you should easily raise his head, and the neck should be bent so that the chin touches the chest. Note if the patient has unusual tension in the neck muscles and if he or she experiences discomfort when lifting the legs into prone positions with straightened knees. Check for enlarged glands on the sides of the neck. Pay attention to whether they are painful to the touch, mobile, soft or indurated.

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Rib cage

Pay attention to how the patient breathes, whether he experiences pain and whether both halves of the chest move in the same way. Does the patient have to sit up to make breathing easier? With the help of a stethoscope, it is necessary to listen to the chest from the front and back and compare both halves of it (see Fig. 125, p. 222 and Table 6, p. 224-227).

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

Sex organs

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

Arms and legs

Check the mobility and strength of the muscles of all parts of the arms and legs. Is there paralysis or muscle weakness? (For example, if the patient cannot move his leg, then you need to find out if this is due to pain or is it a true paralysis, in which pain usually does not occur.) Is there swelling and soreness? What is the condition of the second arm or leg?

Is there pain or deformity? It is necessary to check if the kidney area is not painful, for which you need to lightly hit it with your fist. This area is located on the side of the spine, between the upper edge of the pelvic bone and the last rib.

Nervous system

Is the patient overly concerned about their illness? Pay attention to the mental state of the patient. Is his behavior rational, is there something unusual in it? Can he indicate today's date and perform simple arithmetic.

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Are his movements coordinated and how is his gait?

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

Symptoms

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

In order to draw any reasonable conclusions on the basis of all the information collected, it must be sorted and organized in a certain way. Related data should be classified in one category. The recommended way of organizing information when consulting a physician by radio is described in Chapter 14, section "External Assistance", p. 341.

Formulation of conclusions

Write down the patient's main complaints, note the body systems that may be affected and ask him additional questions regarding these symptoms. You can repeat the physical examination and note the body systems in which abnormalities are found. If necessary, ask the patient additional questions or re-examine certain areas of the body. This will help clarify your observations. Often, by exclusion, you can stop at several alleged diagnoses. Then turn to those chapters of this book that describe probable illnesses or conditions, and decide which one is most consistent with all the symptoms observed in the patient. After reviewing the material in these chapters, you may come to the conclusion that additional tests are needed or that the patient needs answers to additional questions.

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

Discharges such as vomit, stools, sputum and urine should be carefully examined, paying attention to their unusual color, consistency and especially the presence of blood. Blood in stools can be bright red, dark brown, or black. In the urine, blood is usually red, but it is not uncommon for blood to be detected only after the urine has settled for several hours. A patient with jaundice usually has dark yellow urine. In order to confirm the presence of jaundice, urine should be poured into a small bottle and shaken vigorously. In the presence of jaundice, the foam will be yellow, while it is usually white. You can compare the urine of a sick person with the urine of a healthy person.

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

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Simulation

Simulation consists in the fact that a person pretends to be sick in order not to work or due to other personal motives. The simulator either has no signs of illness at all, or he tries to portray them as more severe than they really are. If sham is suspected, take a thorough medical history and carefully examine the patient, in particular, take his temperature and count his pulse.

Treatment

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

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Chapter 4

Help for the victims

Sterilization

General rules wound treatment

Internal damage

Head injury

Eye injury

Ear damage

Nose injuries

Damage to the mouth and teeth

Stretching

Applying bandages

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

Sterilization

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

Dressings must be prepackaged and sterilized.

There are two ways to sterilize instruments:

Instruments and materials can be prepackaged and factory sterilized. They are designed for single use and are very easy to use.

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

The person assisting the wounded must also take measures to prevent infection:

Roll up sleeves;

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

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

HEREDITY - father - chronic viral hepatitis C

BAD HABITS - according to the words - since the age of 18, the patient has been drinking dry white wine 2 times a week. August was abused alcoholic drinks: 6 glasses of dry white wine daily. I do not smoke. Does not use drugs.

OBJECTIVELY.

Weight - 78 kg Height - 188cm BMI = 22.3 kg / m 2

The general condition is relatively satisfactory. Consciousness is clear. The position is active. The physique is correct. The type of constitution is normosthenic. Increased nutrition. The skin is icteric, insolated, the sclera is yellow. Mucous membranes of normal moisture. The shape of the neck is normal, its contours are even. On the anterior surface of the neck in the area of ​​the right carotid artery there is a scar without signs of inflammation measuring 2x2 cm. On the upper shoulder girdle, the consequences of a sunburn are visualized in the form of pigmented confluent spots in the area of ​​the shoulders and between the shoulder blades. The thyroid gland is not enlarged, its structure is heterogeneous on palpation. There are no edema. Palpation of the paravertebral zone, percussion of the spinous processes of the spine is painless. Movement in the joints and spine in full.

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

RESPIRATORY SYSTEM. Chest of the correct form. The supraclavicular and subclavian fossae are pronounced, the same on both sides. Intercostal spaces are not expanded. The respiratory rate is 16 per minute, respiratory movements are rhythmic, of medium depth, both halves of the chest evenly participate in the act of breathing. On auscultation over the lungs, vesicular breathing is heard. There are no wheezes.

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

URINARY SYSTEM. The lumbar region was not changed during examination. Kidneys in standing and supine positions are not palpable. Tapping on the lumbar region is painless on both sides.

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

On the 8th day there was a short-term loss of consciousness (there were no convulsions). Upon arrival in Russia, Murmansk, due to deterioration in the form of increased jaundice of the skin, he sought medical help at the Pulmonology Department of Murmansk, Department of Pulmonology, Murmansk, where he was diagnosed with: Chronic toxic hepatitis, exacerbation. Concomitant diseases: Gastroesophageal reflux disease. Reflux esophagitis. Superficial gastroduodenitis. Biliary dyskinesia. Chronic cholecystitis. Chronic pancreatitis, remission phase. Iron deficiency anemia of moderate severity.

In the hospital, an increase in body temperature up to 40C was noted. On the background of the treatment, the temperature returned to normal.

Within six months, he notes a decrease in body weight by 20 kg, of which over the past 2 months he has lost 10 kg.

Diagnostic and therapeutic measures were taken:

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

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

Fibrogastroduodenoscopy from 31.08.2017 : There were no signs of esophageal varicose veins.

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

Procedure for extracorporeal continuous correction of hemostasis from 07.09.2017 to 08.09.2017.

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

Consulted by the professor of the TUV-2 Department of the Military Medical Academy - inpatient treatment in the gastroenterological department was recommended.

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

A preliminary diagnosis can be made:

Basic: Acute toxic hepatitis, high degree activity

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

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

In terms of differential diagnosis, it is necessary to exclude: autoimmune liver disease, viral hepatitis, cholelithiasis, liver cirrhosis.

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

The main directions of therapy: regimen, diet, drug therapy: antacids, secretolytics, antispasmodics (for details, see the prescription list).

The purpose of hospitalization: relief of complaints, verification of the diagnosis.

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

The planned duration of treatment is 14 days.

Head of the department Sharap O.S.

Clinical resident Ismailova M.E.