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/ Lung abscess and bronchiectasis / Clinical cases

Clinical cases
Отĸрыто: Среда, 28 деĸабря 2022, 10:00
Сроĸ сдачи: Среда, 28 деĸабря 2022, 21:00

! Пройдено

Clinical case 1

Patient C, 19 years old, a student, complains of a

constant, mainly morning cough with mucopurulent
sputum discharge in an amount of up to 50 ml,
shortness of breath when performing increased
physical activity, increased weakness, fatigue,
sweating. With active questioning, notes the recurrent
feeling of heaviness, "discomfort" in the
subscapularis. Several times noted the appearance of
streaks of scarlet blood in the sputum.

History: Born prematurely. Persistent cough with

phlegm since childhood. In childhood, noted frequent
(annually) pneumonia, mainly of the lower lobe
localization. Lagged behind in physical development
from peers. Was released from physical education at
school. Family history was unremarkable. Smokes
from 14 years old, 1 \ 2 packs per day. Allergic history
is not burdened.

Physical examination: satisfactory condition. Body

temperature - 37.0C. Patient with low nutrition. The
skin is of normal color, slightly high humidity, clean.
Peripheral lymph nodes are not enlarged. No edema.
The chest is asthenic. Percussion in the lower parts of
the lungs is determined by a slight dullness of the
percussion sound. On auscultation in the upper and
middle parts of the lungs, hard breathing is heard, in
the lower parts - vesicular, somewhat weakened,
moist fine and medium-bubble rales are determined,
in the interscapular region and in the lower regions on
both sides when forced expiration is performed - dry
rales. RR-18 per minute SaO2-98%. The heart sounds
are clear, the rhythm is correct, there is no noise,
heart rate is 98 per minute, blood pressure is 100 \ 70
mm Hg. The abdomen is soft and painless on
palpation.

General blood test: Hb - 146 g / l, erythrocytes - 4.34

× 1012 / l, leukocytes - 8.7 x 109 / l, leukocyte formula:
no features, ESR - 23 mm / h. Biochemical analysis of
blood was normal. General urine analysis: beats.
weight - 1019, protein - negative, leukocytes - 1-2 in
the field of view, erythrocytes - 1-2 in the field of view,
no cylinders. ECG: sinus rhythm, heart rate - 91 bpm,
focal and diffuse changes were not revealed.
Computed tomography of the chest organs:
bronchiectasis in the lower lobes

бэб

Questions.

1. Formulate a preliminary diagnosis.

2. List the clinical signs on the basis of which this

diagnosis was made.

3. What are the treatment tactics and preventive

measures at the moment?

Clinical case 2
Patient S., 56 years old, complaints of persistent
cough with discharge of a large amount (more than
200 ml / day) of purulent sputum with an unpleasant
odor, periodically - streaked with blood, for expiratory
dyspnea with minor physical exertion, fever up to 37.8
° C , a feeling of "heaviness", pain in the lower calving
of the chest on the left, aggravated by deep breathing,
coughing, weakness, increased fatigue, sweating,
decreased appetite.

Anamnesis: The patient smokes for 40 years up to a

pack a day. Cough worries during all this time, at the
beginning of the disease - morning, with a small
amount of mucous sputum, over time the cough has
become permanent. I began to lose weight.
Exacerbations of COPD - 3-4 times a year, after acute
respiratory viral infections, hypothermia. It is treated
permanently with a diagnosis of "COPD,
exacerbation" with antibiotics, bronchodilators
(berodual, aminophylline), mucolytics  (bromhexine,
ACC) - with improvement. A real exacerbation - 5 her
back, after another hypothermia. Professional history:
works as a chauffeur, notes frequent hypothermia at
work. Family history: mother, 76 years old, suffers
from hypertension, father, 78 years old, practically
healthy. He is married and has a 14-year-old son.
Allergic history is not burdened.

On examination, the condition is moderate. Body

temperature 37.6 ° C. The skin is clean, moist,
acrocyanosis. The terminal phalanges of the fingers
are in the form of "drum sticks", the nails are in the
form of "watch glasses". The physique is
normosthenic, the chest is cylindrical, the
supraclavicular and subclavian fossae are smoothed.
The ribs run horizontally, the intercostal spaces are
widened. There is a lag of the left half of the chest in
the act of breathing. Respiratory rate - 22 in 1 min. On
palpation, the chest is painless, rigid. Vocal tremor is
weakened, but its some strengthening is noted in the
lower parts of the left. With comparative percussion
over the lungs, a boxed sound, on the left below the
angle of the scapula and in the left axillary region - its
dullness. On auscultation of the lungs, breathing is
hard, with a sharply lengthened expiration, in the
expiratory phase, dry humming rales are heard, on the
left below the angle of the scapula and in the left
axillary region, moist large-bubble rales are heard
against the background of weakening of vesicular
breathing. SaO2-93%. Heart sounds are muffled,
rhythmic, 98 beats / min, an accent of the II tone over
the pulmonary artery is heard. Pulse - 98 beats / min
ВР - 130/85 mm Hg. The abdomen is of the correct
shape, the upper half of the abdomen is actively
involved in the act of breathing.

general blood test: Hb - 150 g / l, erythrocytes - 4.9 ×

1012 / l, leukocytes - 11.7 × 109 / l, eosinophils - 3%,
stab - 9%, segmented - 56%, lymphocytes - 30% ,
monocytes - 2%, ESR - 35 mm / h. Sputum analysis:
purulent, viscous, squamous epithelial cells-6-8,
leukocytes - all over, mainly neutrophils, erythrocytes
- a large number. VC, atypical cells were not found.
General urine analysis:  - 1015, protein - traces,
leukocytes - 3-4 in the field of view, erythrocytes - 1-2
in the field of view, no cylinders. Biochemical blood
test: 

CRP-22 mg / l, fibrinogen - 6.5 g / l, total protein - 58.0

g / l, other indicators are within normal limits.
Microbiological examination of sputum: P. aeruginosa
10/6, sensitive to meroneme, amikacin, tobramycin,
cefotaxime, ceftazidime, ceftriaxone, cefepime,
ciprofloxacin, was isolated.

X-ray of the chest cavity organs: the chest is

expanded in the anteroposterior size, the
transparency of the lung tissue is increased, the roots
of the lungs are unstructured.Changes in the
pulmonary pattern in the lower segments of the left
lung, there is also a cavity with a fluid level

абсцесс

Bronchoscopy: the mucous membrane of the trachea

and visible bronchi is hyperemic, edematous, easily
vulnerable, folds are smoothed, on its surface there is
a small amount of mucopurulent secretion,
endoformations in the examined bronchi were not
found. The mouth of the lower lobe bronchus on the
left is deformed, the mucous membrane in this place
is sharply hyperemic, edematous, when coughing, a
large amount of purulent sputum is released from the
mouth. No visible sources of bleeding were found.
Washes were taken for microbiological research,
mycobacteria, atypical cells. The purulent secret has
been removed if possible.

Electrocardiogram: sinus tachycardia - 105 beats /

min, vertical position of the electrical axis of the heart,
overload of the right atrium;PQ - 0.15, QRS - 0.10, QT -
0.38.

Questions.

1. Formulate and justify the clinical diagnosis

2. What additional research methods should be

prescribed to this patient?

3. What is the treatment tactics for this patient?

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Последнее Среда, 28 деĸабря 2022, 13:08

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