home
about the project
Medical news
For authors
Licensed books on medicine

DEPARTMENT OF EMERGENCY MEDICAL AID MGMSU TASKS FOR STATE EXAMINATION

Dodelia V.Sh.



The absence of laboratory and instrumental methods of examination at the prehospital stage of emergency and emergency medical care obliges the doctor to be fluent in the methods of propaedeutics and medical history (there is nothing else). Therefore, we attach great importance to the descriptive part of such tasks, i.e. some tasks are voluminous in content.







Problem number 1. On a frosty morning you head to the train station. Ahead is a tall middle-aged man with a long mustache and smoking a pipe. He is warmly dressed, carries a large backpack behind his back, from which fishing gears intended for winter fishing are visible. Suddenly, the man staggered and fell face down.



1. The algorithm of the doctor?



Answer:

Come up. Hail without touching. If there is no answer, touch, shake lightly. If responding to the examination, determine the level of consciousness, breathing (explain all the options). If there is no answer - palpation of the carotid arteries. Ripple is there or not (explain all the options). The student argues from the simplest option - fainting to the most difficult - stopping blood circulation with tactics and first aid techniques. The diagnosis should take no more than 10-15 seconds, and before the start of medical care - no more than 30-40 seconds.

A typical mistake is to remove the backpack first. The backpack is removed only if the patient needs to be turned on his back for mechanical ventilation or cardiac massage.

The second difficulty is a large mustache, which makes it difficult to conduct ventilation “from mouth to mouth,” the student should pay attention to this circumstance.

Additional questions may relate to the etiology and pathogenesis of any “intermediate” state: fainting, coma, thromboembolism, fibrillation of various heart chambers, etc. It is necessary to know all the possible cause-effect relationships of this condition.





Task No. 2. A man with a traumatic shock of the first degree, a victim in a car accident, was delivered to the in-patient department of the hospital.

An narcotic anesthesia and electrolyte solutions were administered intravenously through the NSR, as well as transport immobilization of the lower limb. Currently, infusion therapy with polyglucin solution is ongoing. Positive dynamics from the ongoing therapy are noted.

The team handed the patient to the doctor of the admission department and left.

During the examination, complaints of dizziness, tinnitus, a sense of fear, lack of air, pain in the lumbar region appeared.

Objectively: a serious condition, in the mind, fully oriented. Bad breath smell of alcohol. The skin is pale, cool to the touch, dry. Red spotted rashes appear on your eyes, accompanied by a dry barking cough, and cyanosis is growing. Difficulty breathing, with the participation of auxiliary muscles, superficial, BH up to 24 per minute. When auscultation is weakened, wheezing is not heard. Ps = heart rate = 125-130 bpm / min, blood pressure 80/40 mm p. Art. The stomach is soft. Pneumatic tire on the left shin.



1. What happened during the infusion therapy?

2. The algorithm of the doctor.

3. Was it possible to prevent this condition?



Answer:

1. Anaphylactic reaction (anaphylactic shock) to the introduction of a solution of polyglucin. Polyglucin solution contains an allergenic dextran, therefore, a three-time biological test is necessary before its introduction. The student should be able to conduct biological tests before infusion of such solutions.

2. Termination of further administration of polyglucin solution, intravenous administration of 0.5 ml adrenaline hydrochloride solutions, glucocorticoids, be prepared for drip infusion of vasopressor amines (dopamine). Repeated administration of narcotic analgesic. Hospitalization in the intensive care unit.

3. Bioassay before the introduction of polyglucin is the prevention of the development of this complication.





Task number 3. Reason for calling the NSR: a 12-year-old boy “suffocates”. Place of call: apartment. Invokes a friend.

At the place of call: a boy of 14 years old (according to documents), a serious condition. Lies on the floor unconscious, does not respond to inspection. Low power. The skin is cyanotic, cool to the touch, dry, on the extremities traces of numerous injections, connected and not related to blood vessels, saphenous veins in the form of “bundles”. The pupils are D = S, narrow, no photoreactions are induced, corneal reflexes are sluggish. Breathing is shallow, weakened, arrhythmic, wheezing is not heard. BH about 8-9 per minute. HELL 70/40 mm RT. Art. Ps = heart rate = 62 beats per minute, weak filling. Heart sounds are muffled, rhythmic. The abdomen is dense along the colon, peristalsis is sluggish. There are no focal signs. For other organs without apparent gross pathology.



1. Estimated diagnosis?

2. First aid.



Answer:

1. Overdose of opiates. Narcotic coma (hypoxemic).

2. Ensuring adequate ventilation: auxiliary or artificial ventilation of the lungs, intravenous administration of the naloxone antidote (0.4 - 0.8 mg), drip administration of warm electrolyte solutions, warming, hospitalization.

It must be remembered that opiate comas occur cyclically, therefore, regardless of the effect of the therapy, hospitalization in the intensive care unit is indicated.





Task number 4. You are a doctor, fly with your family on the plane. Flight altitude 9000 meters. Suddenly you heard a strong clap and then a deafening roar, the interior is filled with dust and fog, visibility is reduced. You feel a ringing in your ears, a cold, and a feeling of lack of air. Next to you is your child, he is losing consciousness. You also manage to notice three oxygen masks hanging in front of you.



1. What happened?

2. The algorithm of actions.

5. What can not be done?



Answer:

1. There was a decompression of the passenger compartment.

4. It is urgent to put on an oxygen mask first to YOURSELF, and not to the child, and securely fix it on your head, and then provide assistance to nearby passengers. Otherwise, you may lose consciousness and drop the mask, then you and the child will be without oxygen. The first and main help in this situation is mask oxygen inhalation. Next, you need to warmly dress in natural fabrics (because synthetic tissue causes severe damage to the skin during burns), remove a tie, scarf, glasses, hair clips, fasten to a chair and get ready for a “solid” fit.

3. It is forbidden to leave your seat until the aircraft stops completely.





Task number 5. The reason for calling the NSR: "a woman of 37 years, headache, blood pressure." Calls mother to the apartment.

At the call site, according to the mother: the patient has been suffering from type I diabetes for 10 years, about which she is taking basic therapy. The last specialist visit more than six months ago.

Today there was a strong feeling of hunger, then weakness began to increase, accompanied by heavy sweating, “became kind of stupid,” a few minutes before the arrival of the ambulance, she lost consciousness and fell.

Objectively: a woman, about 40 years old, lies on the floor near the bed, is in a serious condition, and there is no consciousness. The skin is clean, pale, severe hyperhidrosis, cool to the touch. The pupils are evenly narrowed, the reaction to light is alive. Breathing is free, even, BH 10-12 per minute. Auscultation over the lungs weakening of vesicular breathing, no wheezing. Pulse = heart rate = 70 per minute, rhythmic. HELL 130/90 mm Hg (with "working" figures 150/90 mm Hg. Art.) Heart sounds are muffled. The abdomen is soft, live peristalsis. There are no focal symptoms and severe injuries on the body.



1. The algorithm of the doctor.



Answer:

Hypoglycemic coma. Intravenous administration of a 40% glucose solution 20 ml three times after 15 minutes. The student should know how much glucose he is injecting in terms of dry matter (10 ml contains 4 g of glucose). If after this there is no positive dynamics, then this is not hypoglycemia. Be prepared for adequate respiratory support. ECG recording between glucose infusions. If the patient regained consciousness and became active, did not receive secondary injuries in the fall, it became possible to perform glucometry and blood glucose levels not lower than the “working” numbers, you can leave him in place with the transfer of the “asset” to the clinic.





Task number 6. The reason for calling the NSR: "a man, 43 years old, food poisoning." He calls himself to the office of a medical firm.

At the call site: complaints of nausea, vomiting twice in the stomach, which occurred 2.5 hours after lunch in a restaurant, weakness, frequent aching back pain associated with movement.

Anamnesis: a 42-year-old man, in the past he was actively involved in weightlifting, suffered from osteochondrosis for a long time, noted frequent pulling pains in the thoracic spine, which he’s already used to, chronic gastritis. Over the past week, occasionally notes nausea, which is associated with an exacerbation of gastritis. Other chronic diseases, allergies denied. Does not smoke, does not abuse alcohol, workaholic, not married. Today, one had lunch in a restaurant, after which the above symptoms appeared.

Objectively: a state of moderate severity, active, conscious, annoyed. High, hypersthenic, increased nutrition. The skin is clean, tanned, moist. BH 16 per minute. Breathing is free, vesicular, no wheezing. Pulse = heart rate = 82 per minute, rhythmic. HELL 110/70 mm RT. Art. Heart sounds are muffled. The abdomen is soft, painless. Palpation of the spine is moderately sensitive, especially in the thoracic region. For other organs and systems without apparent pathology.

On the ECG, the acute phase of large focal left ventricular myocardial infarction in leads III, AVF, additional leads V7, - V9 and D in the sky.



1. First aid.



Answer:

Narcotic anesthesia, nitrates, aspirin. Hospitalization in cardiopulmonary resuscitation.





Task number 7. Reason for calling the NSR: a 55-year-old woman "suffocates". Place of call apartment, calls itself.

A 55-year-old patient has long suffered from infectious-allergic bronchial asthma. Real deterioration over the course of a few hours when a feeling of lack of air appeared. Prior to “03,” she used the salbutamol inhaler three times with varying success. Called "03".

On examination: a state of moderate severity, in consciousness, a forced situation, he is reluctant to answer questions. The skin is pale pink, moist, acrocyanosis, swollen cervical veins. The exhalation is very elongated, breathing is frequent, shallow. BH 24 per minute. A boxy percussion sound is noted above the lungs, hard breathing, a lot of dry wheezing is heard. Ps = heart rate = 100 / minute, rhythmic. HELL 150/90 mm RT. Art. Heart sounds are muffled, tachycardia. For other organs without features.



1. Estimated diagnosis?

2. First aid.



Answer:

1. An attack of bronchial asthma.

2. Inhalation of a moistened oxygen-air mixture, inhalation of a berodual through a nebulizer or intravenous administration of aminophylline.





Task number 8. Reason for calling the NSR: a 50-year-old man "died"? Place of call apartment, calls the wife. Call arrival time is 8 hours 55 minutes.

At the call site, the social environment is calm. According to the wife’s words, the husband works a lot, denies chronic diseases, hasn’t visited doctors for several years, without bad habits. The night before, he said that he was very tired. At dinner, I drank 50 ml of brandy, went to bed in his office. The next morning, the wife found her husband "cold, dead" in his bed. Called "03".

On examination: the man is about 50 years old, is in serious condition, does not respond to the examination, consciousness is absent. Lies in bed in a natural position without visible signs of violence. The skin is clean, pale, hyperhidrosis, cool to the touch. Pupils moderately dilated, D = S, photoreaction and corneal reflexes preserved. On the carotid arteries, pulsation is determined. BH = 10-11 per minute. Breathing is weak, shallow. HELL 100/60 mm RT. Art. Heart sounds are muffled, rhythmic. Heart rate = 60 / minute. The stomach is soft. Head on examination without apparent pathology. There are no focal and meningeal signs.



1. Estimated diagnosis.

2. Medical tactics.



Answer:

1. Coma.

2. The task of differential diagnostics com. The student should know the algorithm of behavior during the diffdiagnosis of an unknown etiology. First, hypoglycemic coma is excluded, as one of the most dangerous. For this, iv administration of a solution of 40% glucose 20 ml three times with an interval of 15 minutes is prescribed. Positive dynamics confirms the diagnosis of hypoglycemic coma. In the absence of positive dynamics, exogenous coma (opiate) is ruled out. With any development of events, it is necessary to remember the constant monitoring of respiratory function! Hospitalization.





Task number 9. Reason for the challenge: a woman 63 years old "bad with heart." Place of call: apartment, calls daughter.

At the call site: complaints of a feeling of lack of air, general weakness, dizziness, fainting, which occurred about an hour ago. According to her daughter, waiting for the ambulance, she went into the kitchen and fell.

Objectively: a woman is about 65 years old, lying on the kitchen floor without visible damage, a serious condition, conscious, listless, dynamic, answers the questions correctly, but slowly with difficulty and monosyllables. The skin is clean, pale with acrocyanosis, covered with sticky sweat. Breathing is shallow, rapid, BH = 20-22 / minute, rhythmic. Weakening of breathing is heard over the lungs, there are no wheezing. Ps = 130-140 / minute, arrhythmic, heart rate deficit is about 40 beats per minute. Heart sounds are muffled, arrhythmic. HELL = 60/30 mm RT. Art. On the ECG, a tachysystolic form of atrial fibrillation is recorded. For other organs and systems - without apparent gross pathology.



1. Estimated diagnosis.

2. Medical tactics.

5. What can not be done in this condition?



Answer:

1. Arrhythmogenic collapse (shock).

2. Therapeutic tactics begins with electric cardioversion with an initial energy of 200-250 J (under short intravenous anesthesia, for example, propafol 100-200 mg).

3. The introduction of antiarrhythmics in conditions of arrhythmogenic collapse (shock) is contraindicated.





Task number 10. Reason for the challenge: a 55-year-old man is "hard to breathe." He calls himself to the apartment.

Complaints of shortness of breath with habitual physical exertion, which has been progressing for the past few days.

Anamnesis: a 55-year-old man suffers from Wakez’s disease (erythremia), and receives basic therapy on an outpatient basis: cytostatics, immunosuppressants, corticosteroids. On the hands there is a result of a general blood test, dated yesterday: Hb 176 g / l, Ht 56%, red blood cells - 8.4 million, ESR 45 mm / hour.

Objectively: moderate state, clear consciousness, active position within the apartment. Body temperature 36.8? C. The skin is hyperemic, a blush on the face; to the touch warm, dry. Breathing quickened to 22-24 / minute, superficial. Auscultatory breathing with a harsh tinge, no wheezing. Ps = heart rate = 100 / min, rhythmic, blood pressure 160/90 mm RT. Art. Heart sounds are deaf, rhythmic. There are no focal changes on the ECG. For other organs without features.



1. First aid.



Answer:

1. The fight against the main pathogenetic syndrome - hemoconcentration, leading to rheological disorders and to blood failure as an oxygen transport system. Therapy "03" is aimed at "unloading" the vascular bed and improving the rheological properties of blood.

Bloodletting, as well as intravenous drip of physiological saline (in order to reduce plasma osmolarity), rheopolyglucin solution (in order to improve blood rheology, however, plasma osmolarity is increased - the decision is made taking into account individual characteristics), heparin. In this case, this is the therapy of respiratory failure. With the effectiveness of the therapy, the patient remains in place with the transfer of the "asset" to the clinic.





Task number 11. The reason for calling the NSR: "a woman, 27 years old, unconscious." The brigade call time is 21 hours 00 minutes.

At the call site: complaints of severe weakness, dizziness, tinnitus, nausea.

Anamnesis: chronic diseases denied. Has a healthy child 4 years old. Marks a delay of menstruation for 12-15 days. In the morning I felt weak, but went to work. In the afternoon, the weakness intensified, released home. At 19h. entered the bathroom, dizzy, then does not remember anything. Mother called "03".

Objectively: a young woman of normal build is on the floor in the bathroom, conscious. The condition is serious, the skin is clean, without visible damage, pale, cyanosis of the nasolabial triangle, severe hyperhidrosis, cool to the touch. BH 25 / min., Breathing shallow, vesicular weakened with a harsh hue, no wheezing. Pulse = heart rate = 110 / min, weak filling, rhythmic. HELL in a horizontal position 90/45 mm RT. Art. (with "working" - 110/70 mm RT. Art.). Heart sounds are muffled, rhythmic. The abdomen lags behind the act of breathing, a dull sound in the hypogastric region is determined percussion, flaccid peristalsis, palpation is painless. There are no discharge from the genital tract. For other organs - without features.



1. Estimated diagnosis?

2. First aid.



Answer:

1. Ectopic pregnancy, 2-3 weeks, intra-abdominal bleeding. Hemorrhagic shock of the I degree.

2. The combination of volume-replacing colloidal solutions and crystalloids: physiological saline (or disol, ie, not containing potassium) and HES (hydroxyethyl starch) solutions - voluven (or infucol).

Or intravenously drip: 0.9% sodium chloride solution; 5% glucose solution; inhalation of a moistened oxygen-air mixture 1: 1; hospitalization in the position of Trendelenburg.





Task number 12. The reason for calling the NSR: “a woman of 35 years old, ill with heart”, calls her mother to the apartment.

At the call site: chronic diseases and allergies denied. About an hour ago there was a quarrel with her husband, he left, "a lump in the throat appeared that could not be removed, then it became difficult to breathe." I didn’t take any medicine.

On examination: a woman of 35 years, a state of moderate severity, conscious, fully oriented, sitting on the couch, excited, scared, tearful. The skin is pale, moist, cyanosis of the face, persistent white dermographism. The speech is intermittent, not complete sentences, logical. Breathing is noisy, quickened, uneven with paroxysms and elongated pauses, periods with the help of auxiliary muscles, “obstetrician's arm”. The pulse is equal to heart rate = 110 beats / min., Rhythmic, blood pressure 140/80 mm RT. Art. She does not express suicidal thoughts. For other organs without apparent pathology.



1. Estimated diagnosis?

2. First aid.



Answer:

1. Hysterical reaction.

2. Seduxen in a dilution of 10.0 physiological solution of sodium chloride in / in slowly. After stopping this condition, left in place.





Task number 13. Reason for the challenge: a woman of 15 years "poisoned with pills." Place of call: apartment, calls mother.

At the place of call: according to the mother, a girl without chronic diseases. Today there was a quarrel between the daughter and the parents: the parents' refusal to let the daughter go to a night disco caused a violent protest from the child, as a result of which she grabbed a box of medicines, locked herself in her room and said that she had decided to poison herself.

On examination: a girl about 15 years old, satisfactory condition of proper physique, moderate nutrition, conscious, active, emotionally labile, excited, capricious, manner. She claims that she’s "tired of everything" and with suicidal intent she took "a handful of different pills." In a more detailed survey, in a confidential conversation, she admitted that about half an hour ago she "ate 2 tablets of suprastin to punish her parents." Now she realizes that she made the wrong decision, regrets, apologizes. The skin and visible mucous membranes are clean, pink, moist, body temperature 36.6? C. Breathing is free, vesicular, no wheezing, BH 17 per minute. Ps = heart rate = 70 beats per minute. HELL 110/70 mm RT. Art. Heart sounds are clear, rhythmic. For other organs and systems without apparent pathology.



1. Estimated diagnosis.

2. First aid.



Answer:

1. Taking pills for suicidal purpose.

2. Наличие суицидальных высказываний с возможным пероральным приемом лекарств, является абсолютным показанием для промывания желудка независимо от дозы и от того, принимал ли больной вообще что-нибудь или нет. После промывания желудка девушка должна быть госпитализирована в психосоматическое отделение (либо вызов психиатрической бригады).





Задание № 14. Повод к вызову: мужчина 53 лет «рвота, без сознания».
Place of call: apartment, the neighbor calls.

At the call site: in a dirty smoky apartment, the smell of vinegar is determined. According to the neighbor, the man is abusing alcohol, the last week is in a state of binge. Today at 9 o’clock I came from the store, went to my neighbor, asked to wake him up at 18 o’clock “and went to my place”. Half an hour later, the neighbor heard the characteristic sounds of gagging. At 18 o’clock she found her neighbor in her own room “unconscious” with traces of vomit on her lips.

When viewed at 18 hours 20 minutes: a sharp smell of vinegar is heard in the room. A half-dressed man of about 55 years old is lying in a dirty bed in a natural position, his right hand is hanging from the bed. The condition is serious, unconscious, does not respond to the examination. The skin is dirty, cool to the touch, on the body there are abrasions and hematomas of various prescription. The skin is gray, dry, traces of vomit with an admixture of blood are visible around the mouth. Breathing shallow, rare, BH = 8-10 per minute. Percussion over the light boxed sound. With auscultation, breathing is weakened, a moderate amount of scattered dry rales. Ps = heart rate = 114 per minute, threadlike. HELL 50/10 mm RT. Art. Heart sounds are deaf, rhythmic, tachycardia. The abdomen is flat, with palpation dense, sluggish peristalsis. The pupils are uniformly dilated, D = S, photoreactions are sluggish. There are no focal signs. About 150 ml of dark (brown) urine was excreted through the urinary catheter.



1. Estimated diagnosis.

2. First aid.



Answer:

1. Poisoning with vinegar essence. Exotoxic shock.

Coma. ONE. Resorptive syndrome, and possibly resorptive-necrotic. Acute vascular insufficiency. Acute heart failure. It is already possible and ARF: dark urine tells us that the dose of the poison did not exceed about 30 ml, part of it could be absorbed (by the way, ALD = 50 ml), the degree of tachycardia does not correspond to the severity of the condition (cerebral edema begins).

2. Tactics: the stomach at the prehospital stage is not washed, because more than 6 hours have passed since the moment of poisoning. There is a high probability of perforation of a hollow organ (stomach).

Narcotic anesthesia, infusion therapy, corticosteroids, vasopressor amines, correction of ARF, symptomatic therapy, hospitalization in a specialized hospital (Center for the treatment of acute poisoning).





Task 15. Reason for the challenge: a 53-year-old man “inappropriate behavior”. Calls mother to the apartment.

At the place of the call: according to the mother, it is known that the son has been abusing alcohol for a long time, this excess lasts more than two weeks. For the last three days, he hasn’t taken alcohol. Today has become inadequate.

On examination: a 53-year-old man, of moderate severity, disoriented in time and space, oriented in his own personality, psychomotor agitation, holds a boot in his hand. The skin is dirty, with a gray tint, covered with large sticky sweat, warm. He is active, constantly on the move, frightened, claims that he sees a sniper in a neighboring house, ready to kill him, so he bends past the window. In the corners of the room “sees spiders”, hits them with a boot. Does not respond to doctor's questions. Ps about 120-125 / minute. After persistent persuasion, allows you to measure blood pressure: 160/90 mm RT. Art. A more detailed examination is not possible due to severe psychomotor agitation.



1. Estimated diagnosis.

2. First aid.



Answer:

1. Alcoholic delirium cancellation.

2. The call of the psychiatric team. If it is impossible to carry out infusion therapy - mild sedation, then the placement of a peripheral catheter, infusion therapy with electrolyte solutions; B and C vitamins; potassium, magnesium ions; beta-blockers; inhalation of an oxygen-air mixture or nitrous anesthesia; symptomatic therapy. No physical violence against the patient - death from AOSCH!

Symptoms of active mental production: hallucinosis, delirium - in response to prolonged intoxication with accumulated degradation products of ethanol (acetaldehyde and formic acid). Psychomotor agitation - increased consumption of energy and oxygen. Circulatory hypoxia.





Task number 16. Reason for calling the NSR: A 50-year-old man “unconscious”. The place of call of the clinic, the doctor calls.

According to the doctor, it is known: a 50-year-old man turned to a local therapist about a week ago without any health complaints in order to obtain a medical certificate for further employment. Previously, I considered myself healthy, I did not contact doctors. Appointed medical examination. The day before, an ECG was recorded, the result of which is scheduled to come today.

Today, being at the therapist’s appointment, he complained of a chest discomfort that had appeared the night before. This symptom either disappeared on its own or recurred. A more targeted survey revealed that such situations have already occurred repeatedly over the past year, but did not cause serious concern on the part of the patient, as were short-lived and passed on their own. Upon examination, the condition is satisfactory. For organs without features. Pulse = heart rate = 82 per minute, rhythmic. HELL 115/75 mm RT. Art. But after 5 minutes, "suddenly turned pale, wheezed and lost consciousness." Diagnosed with clinical death, resuscitation measures started. IVL from mouth to mouth, closed heart massage, as well as i / m injected: analgin, papaverine, no-spa, atropine, diphenhydramine.

At the time of the doctor’s examination, the patient was diagnosed with biological death of a man of 50 years old. On the ECG shot the day before, an acute large-focal high upper-lateral myocardial infarction is determined (or, as Q-infarction is now saying).



1. Comment on the problem, what mistakes are made?

2. Could there be another scenario development?



Answer:

1. If a patient who has not contacted him for many years (initial treatment) consults a local doctor, this should be an occasion to treat such a patient as scrupulously as possible. A detailed, detailed history, especially considering the gender and age of the patient. The ECG should be decrypted right away. It was necessary to give the patient nitroglycerin (to conduct a nitroglycerin test).

2. Of course, if you immediately decrypt the ECG. And even a nitroglycerin test during the examination could increase the patient's chances.





Task 17. Reason for calling the NSR: a 35-year-old man “suffocates”. Place call apartment, calls girlfriend.

At the place of the call: a drunk woman meets you and leads you to a sick “friend” who is “hard to breathe.” You find yourself in a cramped, dirty apartment with empty bottles scattered all over the place, food debris and dirty clothes. On an unfolded sofa, an indefinitely aged man fell apart, half dressed in dirty clothes, with a smoking cigarette in his hand and cursing with obscene language. The condition is serious, conscious. Noteworthy: alcohol habit, pronounced gray cyanosis with a pale skin tint, breathing is difficult, shallow. The NPV is approximately 22-24 per minute. Answers questions correctly, fully oriented, but aggressively refuses to examine and treat: "you only need to heal someone." It is hardly known that the third day is sick, when a rise in body temperature to hectic numbers is registered, it was treated independently with "folk remedies", an alcoholic solution of hawthorn purchased in a pharmacy (it contains strong ethanol). Dyspnea has been increasing since yesterday, the patient associates this fact with the end of the dose of the medicine, asks to sell him several bottles of alcohol extract of hawthorn, learning about the absence of this medicine by ambulance, loses interest in the conversation and asks to vacate the room. The patient refuses examination, therapy and painting on the call card.



1. Is a patient or a bully in front of you?

2. Medical tactics at DHE.



Answer:

1. Severe patient, apparently with lobar pneumonia.

2. Try to clearly explain what is happening and what awaits him in the near future. If the conversation took place and the patient agrees to the examination, then conduct an examination. The decision is made based on the result of the inspection. If the situation does not change, inform the duty doctor of the operational department about what is happening, call the special team. If you are a doctor of the special team, you can leave the patient in place after notification (permission) of the responsible physician of the operational department with an “asset to yourself”.





Task number 18. Reason for calling the ambulance: a 40-year-old man "stomach ache, vomiting." Place of call apartment, calls the wife.

Complaints when examined for cramping abdominal pain, vomiting.

Anamnesis: denies chronic diseases; epidemiological history is not burdened. Three years ago he was operated on for acute appendicitis. Today there are abdominal pains, repeated vomiting, which does not bring relief.

Objectively: a state of moderate severity, clear consciousness. The skin is pale. Pulse 90 beats per minute, blood pressure 130/70 mm RT. Art. The tongue is dry, coated with a brown coating. The abdomen is moderately swollen, asymmetric, participates in the act of breathing. On palpation painful in the umbilical region. A positive symptom of “splashing noise” is determined. There are no symptoms of peritoneal irritation.



1. Estimated diagnosis.

2. First aid.



Answer:

1. Intestinal obstruction.

2. Thoroughly inspect all typical places of possible localization of the hernia in order to exclude an injured hernia. The introduction of a nasogastric tube, the evacuation of gastric contents. The nasogastric tube is not removed and remains for the entire period of transportation of the patient. Peripheral vein catheterization. Intravenous antispasmodics, infusion of electrolyte solutions, preferably with a high content of chlorine (vomiting): saline, Ringer's solution, acesol, disol (any of the drugs in a volume of at least 400 ml iv drip). Hospitalization.





Task number 19. Reason for calling the NSR: a 43-year-old man “hanged himself”. Place of call apartment, calls mother.

According to the mother, it is known that she has been abusing alcohol for a long time and is registered with the IPA. The last days he “drinks as usual”, this morning he performed self-hanging in front of his mother. Mother immediately crossed the rope with a knife lying on the table, freed her neck from the loop and called up the ambulance.

On examination: a half-dressed man, about 50 years old, is lying on the floor, his condition is extremely serious, agony, Bad breath smell of alcohol. The pupils are uniformly wide, the corneal reflex is sluggish, no photoreactions are caused, pronounced cyanosis of the face and neck, petechial rashes on the skin of the face and mucous membranes. At the neck level, a high strangulation groove with a knot in the area of ​​the large occipital tubercle is determined. Sluggish and rare clonic-tonic convulsions. Arrhythmic breathing, superficial 6-8 per minute. The pulse is arrhythmic, threadlike. HELL 210/115 mm RT. Art. Traces of urine and stool on underwear.



1. Medical tactics at the prehospital stage.

2. If fatal, name the genus, species, category of death.



Answer:

1. Total curation, tracheal intubation, mechanical ventilation, decongestant, sedative and anticonvulsant therapy.

2. Violent onset of death from mechanical asphyxiation, suicide.

Genesis of disorders: acute violation of the arterial and venous blood circulation of the brain, followed by swelling, swelling and wedging of the brain into the large occipital foramen, impaired vital functions: hemodynamics, gas exchange ...





Task number 20. Reason for calling the ambulance: a 58-year-old woman "indomitable vomiting and diarrhea." Place of call apartment, calls itself.

Anamnesis of the present disease. She fell ill sharply a day ago after eating wild mushrooms purchased on the market. There were abdominal pains without a clear localization, diarrhea 10-12 times a day and repeated vomiting. "Washed" the stomach, took the "smectus", drank strong tea - there was no effect. On the contrary, it notes an increase in general weakness, palpitations, dizziness, and fainting twice. For several hours, periodically detects interruptions in the work of the heart.

When examining the NSR: a serious condition, conscious, passive, lies on the bed. Body temperature 37.8? C. The skin is pale, dry, tongue dry, coated with a dark coating, subicteric sclera. In the lungs, vesicular breathing, no wheezing, NPV 20 per minute. Pulse 96 per minute, rhythmic, weak filling, blood pressure 90/40 mm RT. Art. The abdomen is soft, swollen, moderately painful with deep palpation, no peritoneal symptoms. Palpable smooth enlarged and sensitive liver. Notes a decrease in the daily amount of urine. There are no focal signs.



1. A preliminary diagnosis.

2. Determine the volume of medical measures based on the estimated duration of transportation of at least 1.5 hours (remoteness of the specialized medical institution and traffic congestion).



Answer:

1. Poisoning by conditionally edible fungi (incubation period of about 4 hours).

2. Infusion therapy: saline, chlorosol or quartasol, as well as a solution of potassium chloride 4% or 10% in a 5% glucose solution (the infusion volume for 1.5 hours should be at least 1.5-2 liters, depending on body weight and hemodynamic control).

As a result of repeated vomiting and diarrhea, severe disturbances in water-electrolyte metabolism occurred. Given the volume and nature of fluid loss, it is also possible to assume the presence of hypopotassium (diarrhea) and hypochloremia (vomiting).





Task number 21. Reason for calling the NSR: a 42-year-old woman "heart failure." Place of call apartment, calls itself.

Complaints: acute interruptions in the work of the heart, severe weakness within 8 hours.

From the anamnesis it is known that over the past six months she lost 15 kg, irritability, tearfulness, and blood pressure rises to 160/90 mm Hg appeared. Art., rapid heartbeat.

Objectively: a moderate state, clear consciousness, active position, moist skin, hyperemia, exophthalmos. On palpation of the thyroid gland - an increase in the gland of 2 degrees. In the lungs there is no wheezing, NPV 16 per minute. Arrhythmic heart sounds, heart rate 130 per minute, blood pressure 160/90 mm RT. Art. The abdomen is soft, painless. The liver is not enlarged.

On the ECG, atrial fibrillation. EOS is normal. There are no focal changes.



1. A preliminary diagnosis.

2. First aid.



Answer:

1. Thyrotoxicosis. Paroxysm of atrial fibrillation.

2. Treatment: intravenous drip of obzidan 5 mg. When stopping rhythm disturbance, the "asset" in the clinic.





Task number 22. Reason for calling the NSR: a man of 65 years "suffocating". Place call apartment, calls daughter.

Complaints of a headache that occurred after emotional stress, within 3 hours the pain intensified, shortness of breath appeared at rest, wheezing during breathing, took 1 pill of Corinfar, shortness of breath intensified; caused by SMP.

Anamnesis: suffers from hypertension for 10 years. Adelfan is taken irregularly, periodically hood.

Objectively: a serious condition, clear consciousness, orthopnea position. Excited, scared. The skin is pale, acrocyanosis. Above the lungs, shortening of percussion sound, auscultation of weakened breathing, a large number of wet rales of various sizes over the entire surface. BH 28 per minute. Heart sounds are rhythmic, heart rate of 100 per minute, blood pressure 230/120 mm RT. Art. The abdomen is soft, painless. On the ECG: sinus rhythm, EOS deflected to the left. There are no focal changes.



1. A preliminary diagnosis.

2. Medical tactics on DE.



Answer:

1. Hypertension II Art. Hypertensive crisis. Pulmonary edema.

2. Intravenously nitroglycerin 10 mg / h, Lasix 100 mg, intravenously fractional morphine hydrochloride, 2.5-10 mg. Hospitalization in BIT.





Task number 23. Reason for calling the NSR: a 78-year-old woman "severe weakness". Place of call apartment, calls itself.

Complaints: severe weakness, dizziness, nausea, single vomiting of liquid, which does not bring relief. These symptoms appeared during the day.

Anamnesis: suffers from hypertension with maximum numbers up to 200/100 mm RT. Art., adapted to 150/90 mm RT. Art., a constant form of atrial fibrillation. He has been taking digoxin for a long time.

Objectively: a serious condition, clear consciousness. The skin is of normal color, swelling of the legs and feet. In the lungs, vesicular breathing, in the posterior basal parts, a small amount of moist finely bubbling rales, BH 22 per minute. Heart sounds are arrhythmic, pulse = heart rate of 50 per minute. HELL 100/50 mm RT. Art. The abdomen is soft, painless, the liver at the edge of the costal arch. Neurological status without features. On the ECG, atrial fibrillation. EOS deviation to the left. Heart rate of 50 per minute. Trough-like ST depression in standard leads.



1. A preliminary diagnosis.

2. First aid.



Answer:

1. IHD: atherosclerotic cardiosclerosis. Hypertension II. A persistent form of atrial fibrillation. NK-2b. Glycoside intoxication.

2. The abolition of digoxin, unitiol 100 mg iv cap, hospitalization in the admission department of the hospital.





Task number 24. The reason for calling the NSR: a 60-year-old man with “atrial fibrillation”. Place of call apartment, calls the wife.

Complaints of heart failure, weakness within 7 hours.

Anamnesis: for 6 years, suffers from attacks of angina pectoris, takes nitrosorbide, periodically feels interruptions in the work of the heart, which pass on their own. Not examined, not treated.

Objectively: moderate state, clear consciousness, active position. The skin is of normal color, no edema. In the lungs, vesicular breathing, no wheezing, BH 18 per minute. Pulse = 100 per minute. Heart rate = 120 per minute. HELL 110/70 mm RT. Art. Heart sounds are arrhythmic. The abdomen is soft, painless, the liver is not enlarged. Neurological status without features. On an ECG, atrial fibrillation with heart rate = 120 per minute. There are no acute focal changes.



1. A preliminary diagnosis.

2. First aid.



Answer:

1. IHD: atherosclerotic cardiosclerosis. Paroxysm of atrial fibrillation.

2. At the doctor's choice: amiodarone intravenously 600 mg or novocainamide intravenously 1000 mg. Hospitalization, as made a similar complaint for the first time.





Task number 25. Reason for calling the NSR: a 25-year-old man is "hard to breathe." Место вызова ледовая арена, вызывает тренер.

Известно, что за час до приезда СМП у фигуриста в парном катании после выполнения упражнения, связанного с удержанием партнерши над головой, внезапно появилась боль в грудной клетке с иррадиацией в надключичную область слева, затрудненное дыхание, упорный кашель. Ранее не болел, считает себя здоровым.

При осмотре: состояние тяжелое, в сознании, бледен, гипергидроз, ЧДД=25 в минуту. Перкуторно над левой подключичной областью отмечается тимпанический звук, там же дыхание резко ослаблено. Справа дыхание жесткое. АД 80/50 мм рт. Art. Пульс 116 ударов в минуту, ритмичный, слабого наполнения. По другим органам без видимой патологии.

На ЭКГ синусовая тахикардия. Амплитуда зубцов Р в отведениях II, III, aVF составляет 4 мм. Наблюдается неполная блокада правой ножки пучка Гиса.



1. Предположительный диагноз.

2. Первая врачебная помощь.



Answer:

1. Спонтанный пневмоторакс.

2. Наркотическое обезболивание внутривенно. Oxygen therapy. При клапанном пневмотороксе по жизненным показания проводится торакоцентез – пункция толстой иглой плевральной полости во II межреберье для эвакуации воздуха. Экстренная госпитализация в отделение торакальной хирургии или в реанимационное отделение.

ЭКГ-изменения указывают на перегрузку правых отделов сердца (Р-pulmonale и блокада правой ножки пучка Гиса).





Задача № 26. Повод к вызову СМП: женщина 70 лет «задыхается, кровохарканье». Место вызова квартира, вызывает сестра.

Жалобы: на чувство нехватки воздуха, кашель с мокротой и с примесью крови. Данные жалобы беспокоят в течение суток.

Анамнез: длительное время страдает гипертонической болезнью, стенокардией напряжения. Сутки назад выписана из стационара, где находилась в течение 20 дней по поводу ОНМК на постельном режиме.

Объективно: состояние тяжелое, сознание ясное, положение с низким изголовьем, диффузный цианоз. ЧДД-20 в минуту. В легких дыхание жесткое, справа в средних отделах дыхание значительно ослаблено. ЧСС=120 ударов в минуту аритмичны, пульс 100 в минуту. АД 110/60 мм рт. Art. Акцент 2 тона на легочной артерии. Живот мягкий, безболезненный, печень увеличена на 3 см от края реберной дуги. Отечность голеней и стоп, варикозно расширенные вены нижних конечностей. На ЭКГ мерцание предсердий. ЭОС отклонена вправо. Глубокий S в I отведении, Q в III отведениях.



1. Предварительный диагноз.

2. Первая врачебная помощь.



Answer:

1. Тромбоэмболия легочной артерии.

2. Антикоагулянтная терапия, госпитализация.
= Skip to textbook content =

DEPARTMENT OF EMERGENCY MEDICAL AID MGMSU TASKS FOR STATE EXAMINATION

  1. Crib. Tasks for the state exam 2011 (Department of Emergency Medicine MGMSU.), 2011
    The absence of laboratory and instrumental methods of examination at the prehospital stage of emergency and emergency medical care obliges the doctor to be fluent in the methods of propaedeutics and medical history (there is nothing else). Therefore, we attach great importance to the descriptive part of such problems, i.e., some problems are voluminous in
  2. Department of Emergency Medicine MGMSU. Tasks for the GOS exam, 2010
    The absence of laboratory and instrumental methods of examination at the prehospital stage of emergency and emergency medical care obliges the doctor to be fluent in the methods of propaedeutics and medical history (there is nothing else). Therefore, we attach great importance to the descriptive part of such tasks, i.e. some tasks are voluminous
  3. Medical ethics and deontology in the work of an ambulance paramedic
    Modern medical deontology includes a set of legal, professional and moral duties and rules of conduct for medical workers in relation to the patient, his relatives and colleagues. Medical ethics and deontology are the accessories of all medicine, all its branches and disciplines, especially clinical ones. To medical personnel working in the ambulance system
  4. Organization of ambulance
    001. The ambulance service is intended for a) the provision of emergency and emergency medical care to all patients and victims, regardless of their location (including those being treated in a hospital) b) the provision of emergency and emergency medical care to patients and injured in emergency hospitals c) conducting medical evacuation measures
  5. Organization of an ambulance service
    Emergency medical care (SMP) is a system for organizing round-the-clock emergency medical care for life-threatening conditions and diseases at the scene and along the way to medical institutions. The main feature of emergency medical care that distinguishes it from other types of medical care is the speed of action. A dangerous state comes suddenly, and his victim,
  6. Doctors and emergency medical staff
    {foto11} Continuation of the table.
  7. The history of the emergence of emergency and emergency medical care
    In case of emergency, requiring immediate medical attention, as well as with sudden exacerbations of chronic diseases, the ambulance is given to patients. The ambulance service represents a state system that covers the whole country and has an extensive network of stations, substations, ambulance hospitals, air ambulance and
  8. General principles for providing assistance to the population by the ambulance team
    General principles of assistance to the population by the ambulance team
  9. Structure and organization of activities of the ambulance service
    In Russia, a system has been created and is functioning to provide the population with emergency medical care with a developed infrastructure. The system of emergency medical care facilities is based on the territorial principle of serving the population and the unity of timeliness and continuity of medical measures at the prehospital and hospital stage. There is a direct correlation between the outcome of severe injuries and pathological
  10. Organization of emergency medical work
    Ambulance service is one of the most important links in the healthcare system in our country. The volume of medical assistance to the population by medical and paramedical teams is constantly growing. In rural areas, under the Central District Hospital established emergency departments. Calls to the population there are almost everywhere served by paramedic teams. In cities, stations were established, and in large
  11. EMERGENCY AND EMERGENCY TACTICS TACTICS
    The standards of tactics for emergency and emergency medical care provide for the primary consideration of indications for the delivery of patients (injured) by ambulance teams to the in-patient departments of hospitals and outpatient clinics. The right tactical decision ensures the delivery of the patient (victim) to the specialized medical institution, determining the optimal amount of emergency medical care
Medical portal "MedguideBook" © 2014-2019
info@medicine-guidebook.com