Etiology - infection of the β-hemolytic streptococcus group A. - the presence of foci of infection in the nasopharynk (angina, chronic pharyngitis, chronic tonsillitis). - Scarlatina. Genetic predisposition. Injuries, atherosclerosis, syphilis
The symptom clinic is manifested in 1- 3 weeks after transferred acute streptococcal infection. Symptoms of rheumatism are expressed in: - pain in the joints (rheumatoid arthritis), which are among the first symptoms of the manifestation of rheumatism; - pain in the heart, sword, rapid pulse; - general weakness, lethargy, increased fatigue, headache; - annular rash; - rheumatoid nodes;
When examining the disease, as a rule, develops after 1-2 weeks after transferred acute or exacerbation of chronic streptococcal infection (angina, chronic tonsillitis, pharyngitis) and begins with an increase in temperature to subfebrile numbers, less often there is a more acute start, which is characterized by a remitting febrile fever ( 38 -39 °), accompanied by general weakness, driers, sweating. At the same time or a few days later, pain in the joints may appear. Skin cover. For the active phase of rheumatism, the pallor of the skin even with a high fever, as well as their increased humidity. In some patients, a ring-shaped or noded erythema appears. The annular erythema is a rash in the form of a pale pink rings, never itchy, painless and not protruding over the skin. They are localized mainly on the skin of the inner surface of the hands and legs, chest, belly, neck. The ring-shaped erythema is a pathognomonic sign of rheumatism, but it is infrequent (in 1 -2% of patients). A nodal erythema is characterized by the appearance of limited seals sealing the skin of the grim color, the magnitude of the pea to the plum, which is usually localized on the lower limbs.
Subcutaneous fatty fiber. Sometimes when inspection, you can reveal rheumatic nodules. They are small, magnitudes with pea, dense, low-lifting, painless formations, elbowedly under the skin, most often in the region of extensitive surfaces of the joints, along the tendons, in the occipital region, on forearm and legs. Rheumatic nodules have a large diagnostic value, but are rarely detected, because they quickly disappear. Joints. The affected joints (more often large - shoulder, elbow, knee, ankle, less common to the joints of the hands and stop) educe, leather over them is hyperemic, hot to the touch. Moves in the joints are dramatically limited. With rheumatic polyarthritis a few days later, acute inflammatory phenomena sneeze, the deformations of the joints never occurs. Rheumatic myocarditis. Patients complain of pain or unpleasant sensations in the field of heart, shortness of breath, heartbeat, interruptions. You can identify the characteristic objective signs of myocarditis. When the heart palpation is determined by a weak, spilled, displaced duck the top push. With percussion: the left limit of relative heart dullness is shifted by the dust due to the dilatation of the left ventricle, the diameter of the heart is increased. With auscultation, the attenuation of I tone is detected on the top due to a decrease in the rate of increasing the intraventricular pressure and slowing down the reduction of the left ventricle. With severe myocardium, accompanied by a significant weakening of the contractile ability of the myocardial of the left ventricle, the diastolic rhythm of the gallop is listened (due to the appearance of the III pathological tone). On the top, the soft systolic noise arising from the relative deficiency of the mitral valve is also often determined. Pulse soft, small, rapid, sometimes arrhythmical. Blood pressure is lowered, especially systolic, as a result of which the pulse pressure is reduced.
Survey Common blood test. General urine analysis. Definition of LE cells according to indications. Definition of a common protein. Definition of protein fractions. Determination of C-reactive protein. Electrocardiography. Determination of streptocinase. Heart radiography. Ehoche (Doppler Ehoche).
An ordinary blood test will help detect the jet protein in the blood. If it is present, it means that a person has a hidden focus of inflammation. In order not to miss the development of glomerulonephritis due to the defeat of the renal streptococcus, urine analysis is prescribed. Attention is drawn to leukocytes, red blood cells, protein, urine density. Detection of antibodies of streptolizin, which is an immune response of a person's body for streptococcal, will also help diagnose rheumatism. Biochemical blood test for revisions will identify the effects of virus and streptococci activities. Diagnosing rheumatism with a radiological study at the very beginning of the disease will not help. With the help of X-ray, you can see the same as with a visual examination: the appearance of unnecessary fluid in the joints and swelling of soft tissue. With the development of rheumatic arthritis using X-ray, it is possible to detect the erosion characteristic of this disease. If the patient does not receive the necessary treatment, the fire of bones is found in the joints, the formation of ankylosis - fixed connections. The cardiogram and echocardiogram will provide information on the damage to the heart muscle.
The treatment of rheumatism is carried out comprehensively and is based on the relief of streptococcal infection, strengthening immunity, as well as the prevention of the pathological processes of the cardiovascular system. 1. Treatment of disease at the hospital. Stationary treatment of rheumatism is aimed at relieving streptococcal infection, as well as the restoration of the functionality of the cardiovascular system. It includes: - A bed regime is prescribed under the acute course of the disease; - for the treatment of rheumatism is prescribed complex or separately, depending on the etiology of the disease, one drug from non-steroidal anti-inflammatory drugs (NSAIDs) and hormones; - to fully relieve the disease, the NSAIDs are used for 1 month or more; - for 10 -14 days, penicillin-row preparations ("Bicyllin" conduct antimicrobial therapy; - if the symptoms of rheumatism are often sharpened or the disease is accompanied by other diseases, the reason for which streptococcal infection has become, for example - chronic tonsillitis, the period of treatment with penicillin increases, or additionally Another antibiotic is appointed: "Azithromycin", "Amoxicillin", "Clarithromycin", "Roxitromycin", "Cefuroxime Axietyl" and others.
- appointed "prednisone", in an individual dose, on the basis of laboratory studies, which in the first 10 days is taken in the initial dose, after which the reception decreases every 5 -7 days by 2, 5 mg, and so to the complete abolition of the drug; - appointed the taking of quinoline preparations, which, depending on the course of the disease, are taken from 5 months to several years; - In the case of serious pathological processes in the throat, the doctor may prescribe almonds. 2. The restoration of the immune and cardiovascular system is prescribed mainly in wellness centers (sanatoriums), in which: - continue to carry out anthevimatic therapy; - If there are still remained, various chronic diseases are born; - prescribe a diet, which includes, first of all, food enriched with vitamins; - prescribe hardening the body; - prescribe therapeutic physical culture.
Periodic visit to the doctor Periodic visits to the doctor is carried out in a local polyclinic, which is aimed at preventing the remission of rheumatism, as well as the prevention of this disease. In addition, at the 3rd stage of treatment of rheumatism: - the preparations of the penicillin row in small doses continue to introduce (1 time in 2 -4 weeks for 1 year); - 2 times a year, instrumental and laboratory studies are carried out; - prescribe a special healing physical education; - continue to strengthen the immunity of vitamins; - 2 times a year, in spring and autumn, along with the use of penicillin, conduct a monthly rate of admission of non-steroidal anti-inflammatory drugs. - If the disease has not been associated with the lesion of the heart, for 5 years after the treatment of rheumatism, then preparations of penicillin row are taken.
The prevention of rheumatism includes: 1. Strengthening the immune system: - Eating enriched with vitamins; - hardening the body; - Sports, always do morning exercises; 2. Periodic visit to the doctor aimed at identifying infection; 3. Compliance with the rules of hygiene; 4. Not the admission of the body undercooling; 5. Wearing loose clothes and shoes. 6. Compliance with the work of work - rest.
Complications of rheumatism If they do not pay due attention on symptoms of rheumatism, and not at the time to appeal to the doctor, these diseases can cause the following complications: - Go to a chronic form, the treatment of which can take up to several years; - develop heartfall; - cause heart failure; - As the result of the failures in the work of the heart, cause violations in the work of the circulatory system, which in turn can provoke strokes, varicose diseases, diseases of the kidneys, liver, respiratory organs, organs of vision, etc. - with exacerbation of all of the above symptoms and diseases lead to death .
Department of propaedeutic and faculty therapy with
Endocrinology and LFK course
Ph.D., Associate Professor Kareline A.P.
Definition
Post-infectiouscomplication
Astreptococcal tonsillitis (angina) or
pharyngitis in the form of system inflammatory
Diseases
Connecting
Fabrics
from
Prediable localization in a cardiovascular system (rheumlock), joints
(migrating polyarthritis), brain (chorea) and skin
(ring-shaped erythema, rheumatic nodules),
developing in predisposed persons
mainly young (7-15 years),
In connection with the autoimmune response of the body on
Antigens
Streptococca
and
Cross
reactivity with similar autoantigren
Affected man tissues.
History
Rheumatism disease is well known andfirst information about him as a disease
Joints
meet
yet
in
Ancient Chinese medicine.
One
of
First
clinic
acute
rheumatic
Migratory
Polyarthritis described Hippocrates. He is also
noted
what
rheumatism
develops
Mostly in young people.
The term "rheumatism" suggested Galen. A classic description of rheumatism Dali
Domestic clinician Sokolsky G.I.
(1836 g) and Frenchman Buhio B. (1835 g) →
Sokolsky-buuche disease.
Botkin S.P. described the systemicity of the defeat
With rheumatism. In 1904 L. Ashoff
described the granule, and in 1830 Talalaev V.T.
produced
Clinico-morphological
Comparison of granules and rheumatism. Rheumatism is registered everywhere and
not
depends
from
Geographic
or
Natural climatic conditions.
But the connection between the level
primary incidence of rheumatism and
Socio-economic
Development
countries.
Morbidity
rheumatism
in
economically
developed
countries
in
The last decades have declined sharply and
is 5 per 100 thousand population. Prevalence
rheumatism
in
developing countries among schoolchildren
ranges from 27 - 116 on
100 thousand
population.
Prevalence
rheumatic
heart defects - 1.4% in the population.
Older than 30 - 40 years old man rheumatism
Practically does not get ill (but sick).
Women sick rheumatism 6 times
More than men.
Patients often detect the II and III
Blood groups.
Etiology
The leading role belongs to β-hemolyticStreptococcus c. A (Streptococcus Pyogenes),
which causes inflammatory defeat
connective tissue, launching mechanism
Education
antibodies
to
Own
Connecting tissues of the body.
In Streptococcus clinic, mainly causes
diseases such as angina, scarletin,
Ryg, impetigo, sepsis.
The most common reason is the defeat of the upper
respiratory tract - in 75% of cases rheumatism
develops after an angina. Features
β-hemolytic
Streptococcus Group A:
Troptitude to the nasopharynk;
high contagiousness;
M-Protein Properties
toxins and enzymes;
education
antibodies
cell
walls
Cross-reactive Ways of infection with streptococcal infection.
Infection is transmitted from a sick person
To healthy airborne droplet
(saliva, wet) when coughing and sneezing,
less than contact-household way (through
Handshake or homemade items
consultation).
Sometimes an outbreak of angina or scarlet
can cause eating
infectious food (most often
milk). A significant role in the development of rheumatism
It has a genetic predisposition.
So in families of patients with rheumatism
repeated cases of the disease occur
3 times more often, and rheumatic vices in 4
times more often than in the population (although not
Calculate and closer communication in
family).
Concordance for rheumatism among
monosic twins is 37%, and
Among heterozygous - only 9%. Social factors in the development of rheumatism:
unsatisfactory living conditions;
power failure (irrational
The ratio in the diet of proteins, fats and
carbohydrates
hypovitaminosis
Low
Calorie food). Immunity reduction:
physical overvoltage, especially in persons
not accustomed to physical exertion;
supercooling
alternate them;
or
overheating
or
physical injury or operation;
emotional stress;
Attachment of intercurrent infection;
Food or medicinal allergies.
Pathogenesis
ConcreteMechanisms
Rheumatism is not clear.
Development
It is assumed
Direct
or
indirect
damage
The impact of cell and extracellular
Antigens
and
Toxins
streptococcus
Conscribing destruction of others
fabrics
Developing
Antitoxic
antibodies
Reduced
Phagocytic
Neutrophil activity, etc. M - cell wall protein (type M5, M6,
M18, M24) - Virulence factor;
Hemolyzines: (Streptolysin-O and
streptolysin- s);
Fibrinolysin (streptocinase);
Hyaluronidase;
Deoxyribonuclease in,
Hyaluronidase;
Proteinase. IN
answer
on the
them
Impact
maybe
form
Anti-Robococcal
Antibodies with pathogenetic
action.
Streptococcus antigens possess the so-called.
"Antigenous Mimicria" i.e. Cross
react with human tissue antigens:
various heart structures (myocardium,
valve fabric), core cores,
vessels. Immune inflammation of heart tissues, in
turn promotes change
antigenic properties of some heart
components, which leads to the transformation
them
in
Autoantigren
from
Development
autoimmune process.
Installed with rheumatism with phenotype
HLA (i.e., with a factor of histocompatibility).
Those.
rheumatism
sick
people
having a defect in the immune system.
Patomorphology
MorphologicalThe basis
Systemic
inflammatory process during rheumatism
is the granule of Ashoffa for which
Characteristic
Phase
the change
connective tissue. mucoid swelling (exudative phase), with
which begins disorganization of the main
connective tissue substances;
fibrinoid changes (proliferative
phase) - exacerbation of disorganization processes and
the emergence of necrosis foci;
fibrinooid
necrosis
–
granule around necrosis foci;
Formation
Sclerosing with the formation of scar
Fabrics. Starting from the fibrinoid phase
Full tissue reparation is impossible
those. The outcome of the formation of granules in this
case - sclerosation - formation
Vice.
Classification (Arr, 2003)
ClinicalOptions
Clinical manifestations
Maintenance
Additional
Fever
Artralgia
Abdominal
syndrome
Sumorosi
Stage of the NK
Exodus
KSV * NYHA **
Acute
Carditis
Recovery
0
0
Rheumchitrite
Chronic
I.
I.
Skye.
Chorea
rheumatic
II.
II.
fever
Collcebolese hearts:
IIB
III
Repeated
prominent
- Discount
III
IV.
Rheumatcheemy
Hearts ***
Skye.
Heart rheumatically ****
fever
Sky nodules
* - according to the classification of Strazhestko-Vasilenko
** - NYHA functional class
*** - Perhaps the presence of post-inflammatory edible fibrosis valve flaps
without regurgitation, which is specified using ECOG
**** - If there are first detected heart defects, it is necessary, if possible, to exclude other reasons for its formation (infectious endocarditis,
Pafs, calcine valves of degenerative genesis, etc.) Phase and degree of activity
Inactive phase
Active phase - 3 degrees of activity
(Minimum I Art.)
Under the inactive phase understand the state
Health in people who moved rheumatism when
During the survey, the dynamics fails
identify signs of the inflammatory process
or impairment impairment.
Under the active phase ...
Degree
Activity
differ
features of the inflammatory process and their
Industion
(Defined
from
Use
laboratory
and
immunological research methods).
The nature of the flow
acutesubacute
Stretty
Continuous - recurrent
Latent acute current
Sudden sharp start
Symptoms of the disease:
fever,
polyarthritis,
Carditis
bright
pronounced
The duration of the attack is usually 2 - 3 months, while
There is no tendency to exacerbations.
Subighteous current
The manifestations of rheumatism are pronounced, but
Symptoms develops somewhat slowly and
rheumatic attack does not wear so aggressive
currents but it stretches over time to 3 - 6
months and has a tendency to exacerbations. stroll flow
Gradual
development
Clinical
manifestations with subsequent monotonous
current without clear periods of exacerbation
and remission.
continuously recurrent flow
Clear alternation of incomplete periods
Remisses with pronounced exacerbations.
Proceeds on the background formed
Pulk heart. latent current
Slow
Chronic
flow
for
lack of clinical manifestations and
laboratory
Signs
Activity
rheumatism.
Ordinary
Diagnostic
studies latent rheumatism
detected, but only on detection
Vice.
The older the age, the more likely
Latent rheumatism.
Clinic
1.Communication
from
Transferred
acute
Str.
infection. In typical cases after 1 - 3
weeks after angina (less often with a friend
Streptococcal disease).
With latent form, communication with infection is not
traced.
For
Rezidivakh
(rheumatic attacks) the term decreases.
Sometimes, with sharp cooling, rheumatism
occurs after 1 - 2 days without visible connection with
infection.
2.
Availability
"Absolute"
Signs
Rheumatism - Kisl - Jones criteria.
3. Proponation
Hearts.
to
formation
Pokov Most
rheumatism
Characteristic
Sign
is an
rheumatic
polyarthritis (poly-, oligo-, mono-) (not
confused with rheumatoid) large joints,
arising in 60 - 70% of cases.
The patient, as a rule, can indicate the day
Or even an hour of starting the disease. Characteristic
Polyarthritis:
Signs
rheumatic
All signs of inflammation: pain, edema,
stiffness
redness,
Violation
functions;
symmetry
lesions
Joints: TB, COP, LS, GSS;
Large
"volatility"
lesions
–
Fast
The rise of symptoms of arthritis and fast
reverse development; acute, very painful sensations (up to
complete immobility);
Full
reversibility
Process:
everything
The articular manifestations of rheumatism disappear
without a trace. Even without treatment they pass
After 2 - 4 weeks. For
Timely
Therapia
Symptoms
rheumatic
Cubs for 2 to 3 days.
Clinical
Polyarthritis
Rheumatic polyarthritis does not give strain.
Very rarely developing postrending
arthritis
Jacket
Character-keny
The deformation of the small joints of the brushes and stop. Differential
diagnostics
arthritis for other RD:
from
SLE for girls
AC for youth
RA, Yura
Lyme disease
Postoprectococcal Rea
Perhaps development at middle age
lack of a short latent period
No cardita
weak
answer
on the
Anti-inflammatory
Therapy. heart damage - 100% of cases
Rheumatism
a heart.
"Licking"
joints
but
"Bites"
All shells can be involved in the process
Hearts, but, above all myocardia,
leaking
by
Type
focal
and
diffuse myocarditis. rheumatic myocarditis flowing
By type of focal myocarditis.
Complaints:
on the
Nonal
Pain
or
unpleasant feelings in the field of heart
Little
Saddy
for
load
heartbeat or interruptions.
Palpatorno:
Determined
miogenic
Dilatics
–
Top push.
Sign
Spilled
Percussive: moderate increase in left. auscultative: signs of insufficiency
Mitral
Valve:
muffling
Tone i tone on the top ("velvet"
tone), the appearance of a soft systolic
Noise on the top.
Sometimes III tone appears, even less often IV.
The reason is a decrease in myocardial tone.
In the absence of heart failure proceeds
not hard.
Violation of other heart functions (ECG)
Conductivity - blockades.
Automatom - tahi- or bradycardia.
Easter exciseness. rheumatic myocarditis flowing
Diffuse type.
Meets G.O. in children.
Pronounced shortness of breath, right up to ortopnoe.
Heartbeat, "pale cyanosis", swelling
Chine
veins.
Expansion
hearts
The emergence of the III tone (i.e. appearance
protodiastolic gallop).
Pronounced changes to the ECG:
↓ Valted teeth, incl. T,
↓ Interval -ST.
Rheumatic endocarditis (Walvulit)
Protect
highly
is hidden
and
Detected
POST.
Factum
Forming a vice.
often
after The term "rheumatic" endocarditis usually
not
Enjoy
but
Used
term
"Revmokartim" Understanding a combination
Myocarditis and endocarditis.
The main feature is auscultative. clear systolic noise with unchanged
Telling tones and no symptoms
Myocardial lesions.
Noise rude, sometimes musical
Tint. The soundness of the tones is increasing when
Change of body position or after load;
The emergence of new
existing tones.
or
the change
already If a
rheumatic
endocarditis
is an
Basic
Sign
rheumatism,
that
is he
Detected
only
for
appearance
Hemodynamic
Disorders
for
Formed pounding of the heart.
When re-rheumatic attack (return
endocarditis) Mitral is more often formed
stenosis. rheumatic pericarditis - 30%
Pain, fridge friction noise, more often along the left
The edges of the sternum. With exudative pericardia -
Dyspnea, increasing heart size, deafness
Tones, swelling of the cervical veins.
Pericarditis can be independent or
Special case of rheumatic polyporosit -
pleurite or peritonitis found only
Children. Differential
myocarditis
VD
diagnosis
from
Other
preceding
Vegetative and endocrine
dysfunction
Frequent connection of the disease with stress
Gradual Beginning of Disease
emotional
Color
Complaints:
respiratory
discomfort, wet hands, feeling of faintness,
Vegetative-vascular crises
No signs of Walvulitis and Pericarditis Infectious endocarditis
Primary PMK.
SKV
Re (urogenital)
Viral myocarditis
Communication with nasophal infection
Lack of latent period
No arthritis
The gradual development of the process
"Active" character of complaints
ECG signs of myocarditis
No Walvulita
Pericarditis develops rarely
Dissociation of clinic and laboratory data
Slow dynamics (NSAVP worsen contractile
myocardial ability) skin lesion
It is found only in children in 1.5% of cases.
The lesion is based on rheumatic vasculitis.
Defeat form - in the form of ring erythema - on
inner surface of the hands, legs, abdomen, neck, torso,
Heat.
Differential diagnosis:
Journal Erythema
Allergic rash
SKV
Lyme disease
Rheumatic nodules - dense low-lifting b / b
Formation of seed grain size to beans.
Localization is the extensible surfaces of the elbow,
knee, plug-in phalangeing joints. Meet
rarely.
joints.
nervous
Systems.
maybe
and
Direct
System.
4 forms of damage to the nervous system are distinguished:
chorea;
acute meningoencephalitis;
chronic meningoencephalitis;
Rheumatic encephalopathy. chorea
The term "Small Chorea" (Greek. Choreia - Dance)
Offered by paracetse.
it
the form
hyperkinosis
Manifesting
fast
disorderly
Nertimichny
Nesterotype,
non-violent
movements of various muscle groups.
Small chorea develops, in general, in 10 - 13%
children, and during the first rheumatic attack
It is observed in 60 - 70% of cases.
Girls meet more often than boys. defeat of the nervous system and senses
With rheumatism damage to the nervous system
stands on the 3rd place after the death of the heart and
joints.
The process is based on vasculitis of vessels
nervous
Systems.
maybe
and
Direct
Toxic and immune impact on nervous
System.
Clinical symptoms develop gradually:
develops
emotional
lability
–
unstable
mood,
Flameness,
irritability, scattering, aggressiveness,
Egoistic, fast fatigue. Then join hypercines and a decrease
muscle tone.
There are non-violent, faded, not
coordinated, gusty movements in
Muscle face, neck, limbs, torso.
Arises
grimacing
Nepny
speech
"Swallowing" individual syllables or integers
words,
Changes
handwriting,
Impossible
keep the table setting items - difficult
To bring a spoon to the mouth, it yourself is, drinking. defeat of the nervous system and senses
With rheumatism damage to the nervous system
stands on the 3rd place after the death of the heart and
joints.
The process is based on vasculitis of vessels
nervous
Systems.
maybe
and
Direct
Toxic and immune impact on nervous
System.
Due to the combination with muscular weakness of the child
It becomes difficult to walk, sit, talk,
to swallow. There are a number of symptoms observed when
Malaya Khorora:
Symptom of "Drying Shoulders" (in very small);
symptom
Filatova
–
Impossible
at the same time close the eyes and narrow the tongue;
Symptom of ink - poverty
Area during inhalation.
Often
Malaya
desire
Vascular dystonia:
accompanied
sweating;
Vasomotor
disorders
red dermographic);
tachycardia;
Pulse lability.
awesome
(persistent In recent decades, changing the clinic
rheumatism led to the appearance of the structures
Atypical forms of small chore. eye damage
In the form of irita and iridocyclitis (iris and cyiliary
body).
acute pain in the eye;
Vessel injection Scler;
tear;
Eveque and conjunctiva.
General manifestations
T °, fever, more often incorrect type. Fever
never accompanied by chills;
Sweating with sour smell;
Loss of appetite, weight loss, sharp weakness, etc.
Diagnostic Criteria Kisl - Jones - Nesterova
1. Cardness:expansion of heart boundaries;
Systolic or diastolic
top heart;
Frillrad friction noise;
ECG changes
2. Polyarthritis:
pain in the joints;
Motion limit
swelling,
lameness;
noise
over 3. Khorora with characteristic involuntary
twitching
Mimic
muscle
and
limbs;
4. Subcutaneous nodes - small, dense, b / b
education near the joints;
5. Round-shaped erythema - recurrent
rash rounded circuit; 6. Rheumatic anamnesis:
Communication with the infection of the upper respiratory
ways;
The presence of rheumatism patients among
family members, neighbors, friends, etc.;
7.
efficiency
Antordrificial
Therapies within 3 - 5 days. Additional manifestations (small):
t °,
Adamina
Fast
fatigue
irritability, weakness, skin pallor
Pokrovov, sweating, nasal bleeding,
abdominal syndrome;
Laboratory: leukocytosis, disproteinemia:
ESO, the appearance of CRH, hyperfibrinogenemia, α2
and γ-globulins;
Immunological: Assl-o, ASK, ASG Titres
Diagnosis reliability
two main and one extra or one
The main and two additional. Laboratory diagnostics
Express method + sowing;
ESO, leukocytosis (anemia is not characteristic)
ASLO, ASG
Disproteinemia.
Treatment
emergency hospitalization;bed mode;
Diet: Restriction
vitamins;
Sololi.
and
raising
NSAID under the articular syndrome;
GKS (15 - 30 mg) with severe myocardium;
Symptomatic therapy: IAPF, antagonists
Ca, diuretics.
Antibacterial therapy of acute a - streptococcal tonsillitis
AntibioticsDaily dose (multiplicity)
Adults
Macrolids
Spiramycin
Azithromycin
6 million units (2)
0.5 g-1st day,
then 0.25 g (1)
Roxitromycin
0.3 g (2)
Clarithromycin
0.5 g (2)
Midekamicin
1.2 g (3)
Erythromycin
1.5 g (3)
Lincoosamida
Lincomycin
1.5 g (3)
Clindamycin
0.6 g (4)
Children
Duration
Treatment (days)
3 million units (2)
12 mg / kg (1)
10
5
5 mg / kg (2)
15 mg / kg (2)
50 mg / kg (2)
40 mg / kg (3)
10
10
10
10
30 mg / kg (3)
20 mg / kg (3)
10
10
Prevention
proper antihine treatment - at least 10 days:Macrolids: Sumamed, Cephalosporins of the 1st
generation;
With recurrent tonsillitis - Penicillin
+ clavulanic acid, lincosamine; Macrolids
do not assign
Observation by
rheumatism.
Children
in
families
Patients
Examples of diagnoses
1.Acute
(mitral
I01.1
rheumatic
fever:
carditis
Walvulitis), polyarthritis, NK I (FC I).
2. Acute rheumatic fever: Khorora. NK 0 (FC 0)
I02.9
3.. Removative rheumatic fever: Cardness.
Combined mitral heart disease. NK IIA, (FC II).
I01.9
4.
Chronic
rheumatic
disease
challenge
Regional
fibrosis
Mitral valve. NK 0, FC 0. I05.9
Hearts:
sash
5.
Chronic
rheumatic
disease
Combined
Mitral-aortic
Hearts. NK IIB, FC III.
I08.0.
Hearts:
vice
Slide 1.
Clade 2.
Plan: Rheumatism Causes Signs of rheumatism Treatment of rheumatism Prevention of rheumatism
Slide 3.
Rheumatism is a disease that develops imperceptibly and gradually. First of all, it damages our heart, blood vessels and joints. Then it gets to the rest of the organs: liver, kidneys and lungs. Such multifaceted manifestations of rheumatism is related to the fact that it does not just destroy some one body. The disease affects a whole group of cells with specific properties (connecting tissue), which are found in our body everywhere.
Slide 4.
Reasons: provoke rheumatism can a number of reasons: supercooling, overwork, defective nutrition (few proteins and vitamins), poor heredity (in the family there were already rheumatists). But the most important thing is that there are special bacteria for the disease - the beta-hemolytic streptococci of the group A. Once inside our body, they cause angina, pharyngitis, scarld. Only if a person has defects of the immune system, the distant consequences of this infection can be rheumatism. According to statistics, only 0.3-3% of people who have undergone an acute streptococcal infection are ill with rheumatism. In rheumatism, Streptococcus begins his destructive activities, in response to this, the immune system begins to produce protective substances that will destroy pathogenic bacteria, their livelihoods, and at the same time damaged cells of their own organism. People predisposed to rheumatism, the immune system comes out from under control. Treaty during the disease, it continues to produce substances that can destroy not only streptococci, but also cells of connective tissue. As a result, the organs where these cells are many, foci of inflammation appear, which over time reincarnate and interfere with the normal operation of the organ.
Slide 5.
Signs: Usually the first signs of rheumatism appear in two or three weeks after angina or pharyngitis. A man begins to feel strong weakness and pain in the joints, the temperature can be dramatically climbed. Sometimes the disease develops very concealed: the temperature is low (about 37.0), weakness moderate, heart and joints work, as if nothing had happened. Usually a person is guessed about hopeless rheumatism only after he appears serious problems with joints - arthritis. Most often, the disease is striking the joints large and medium: pain in the knees, elbows, wrists and footsteps. Pouring sensations can sharply appear and also dramatically disappear, even without treatment. But it is not necessary to be mistaken - rheumatic arthritis has not disappeared anywhere. Another important sign of rheumatism is heart problems: pulse frequency disorders (too fast or too slow), interruptions in the heart rhythm, heart pain. Human concerns pronounced shortness, weakness, sweating, headache. Rheumatism can affect the nervous system. In this case, there is an involuntary twitching of the muscles of the face, legs or hands, like a nervous tick. If it is not treated, rheumatism will hurt almost all the organs, and the person will quickly turn into ruins. Major misfortunes: polyarthritis, which can lead to complete immobility, and a card holder who threatens a real vice heart. Children more often encounters acute flow of rheumatism: the disease turns around in about two months. For the first time, sick adults takes 3-4 months.
Slide 6.
Treatment: Treatment of rheumatism is based on the early appointment of complex therapy aimed at suppressing streptococcal infection and activity of the inflammatory process, preventing the development or progression of heart defect. The implementation of these programs is carried out according to the principle of stratification: the 1st stage - inpatient treatment, the 2nd stage - the fill in the local cardio-rheumatological sanatorium, the 3rd stage - dispensary observation in the clinic. At the 1st stage in the hospital, the patient prescribes medicinal treatment, correction of nutrition and therapeutic physical culture, which are determined individually taking into account the characteristics of the disease and, above all, the severity of the heart damage. Due to the streptococcal nature of rheumatism, treatment is carried out by Penicillin. Antipershair therapy provides one of non-steroidal anti-inflammatory drugs (NSAIDs), which is prescribed isolated or in a complex with hormones depending on the indications. Penicillin antimicrobial therapy is carried out within 10-14 days. In the presence of chronic tonsillitis, frequent exacerbations of focal infection, the duration of treatment with penicillin increases, or an additional antibiotic is used - amoxicillin, macrolides (azithromycin, roxitromycin, clarithromycin), cefuroxime Axietyl, other cephalosporins in the age dosage.
Slide 7.
NSAIDs apply at least 1-1.5 months before eliminating the signs of the activity of the process. Prednisone in the initial dose is prescribed within 10-14 days before the effect is obtained, then the daily dose is reduced by 2.5 mg every 5-7 days under the control of clinical and laboratory indicators, subsequently the drug is canceled. The duration of treatment with chinoline drugs during rheumatism is from several months to 1-2 years and more depending on the course of the disease. In the conditions of the hospital, the elimination of chronic foci of infection is also carried out, in particular, the removal of almonds carried out in 2-2.5 months from the beginning of the disease in the absence of signs of the activity of the process. In the 2nd stage, the main task is to achieve full remission and restoring the functional ability of the cardiovascular system. In the sanatorium, the therapy continues in the hospital, the foci of chronic infection is treated, carry out the corresponding medical and wellness regime with differentiated motor activity, therapeutic physical education, challenge procedures.
Slide 8.
At the 3rd stage of complex therapy of rheumatism provides for the prevention of relapses and progression. For this purpose, preparations of penicillin extended action, preferably Bicyllin-5, the first introduction of which is carried out still during the period of inpatient treatment, and later - 1 time in 2-4 weeks year-round. Regularly, 2 times a year, an outpatient examination is carried out, including laboratory and instrumental methods; Prescribe the necessary wellness activities, therapeutic physical education. Children who suffered a rheumorphitis, in the presence of a valve heart rate, the bicyllinoprophylaxis is carried out until the age of 21 and more. With rheumatism without the involvement of the heart, the bicyllinoprophylaxis is carried out within 5 years after the last attack. In the spring-autumn period, along with the introduction of Bicillin, a monthly NSAID rate is shown.
- Rheumatism - infectious-allergic disease, affecting the cordial and vascular system (endocardium, myocardium, less often pericardium) and large joints.
- As a result, deformations of the valve apparatus of the heart are developing and heart disease is formed. The defeat of the joints (mostly large) is rarely observed, only in the active phase of the disease, and during its elimination of the deformations of the joints does not remain.
- Rheumatism is a chronic disease, proceeds with periods of exacerbation (active phase) and remission (inactive phase). The active phase of the disease is also called a rheumatic attack.
- Etiology. It is assumed that infection (most often hemolytic streptococcus group A) is important in the occurrence of rheumatism. However, the infection has the value of the starting mechanism, and in the future, with exacerbations, its role is reduced.
- Contracting factors. The development of rheumatism contributes to the supercooling, unfavorable social conditions, working conditions (work in the cold room), heredity. The primary attack of rheumatism occurs more often in childhood and young age.
Clinic
- The disease begins most often after 2-3 weeks after the suffered angina (exacerbation of chronic tonsillitis, acute respiratory infection). These same diseases may further be significance in exacerbation (relapses) of rheumatism.
- General malaise, the body temperature increases (more often to subfebrile numbers), weakness, decrease in appetite, performance.
- Rheumatic polyarthritis: Pain in large joints when moving, joints are often increasing in the volume, the skin is blushing over them, it is also characteristic of volatile pain (then the other joint is inflated). Under the influence of treatment, all pathological changes in the joints completely disappear, the mobility is restored, but the pathological process continues in the cardiovascular system.
4. Defeat of the cardiovascular system: It is manifested by unpleasant sensations in the field of heart, interruptions, palimetings, a small shortness of breath.
- Round-shaped erythema
6. Rheumatic knots around the joints
7. Chorea - Defeat of the nervous system. The chorea is characterized by an increase in motor activity (hyperkines): children spill the contents of plates and cups, drop the spoon from the hands, the gait is broken, the handwriting changes (letters become uneven, jumping). The child often makes grimensions, moves it somewhat frosted and unnatural. Usually at this time adults and teachers regard the behavior of the child as a prank and often punish it. Gradually, all major muscle groups are involved in the pathological process. The case sometimes comes to the so-called motor storm, depriving the child's ability to move and serve themselves.
Objective data
- When examining the patient in the active phase (acute period of the disease), there is an increase in the joints in the amount (most often knee, ankle, elbow, wilderness), limiting their mobility. The skin can be hyperemic, edema.
- The muffledness of the heart tones is observed, a slight systolic noise at the top; Sometimes rhythm disorders - extrasystole, tahi - or bradycardia. All these signs are a manifestation of the lesion of the muscles of the heart (rheumatic myocarditis, or rheumborty). If myocardia is amazed significantly, signs of heart failure may appear in the form of distinct shortness of breath, increasing the liver, of nonresopable edema; The heart bounds are clearly expanded.
- After the attack of rheumatism in most cases, heart defects are formed:
- mitral valve failure - 0.5 years,
- stenosis of the hill valve - after 1.5-2 years.
- Part of the patients with timely early treatment and sufficient duration of the heart disease does not occur. Most often, the vice is formed after the second and even the third attack of rheumatism.
- As a rule, during repeated attacks, the joints are amazed significantly less often, only volatile pains in the joints are noted more often (the so-called arthralgia). In addition, subfebrile body temperature, deterioration of general well-being, sweating, reduction of tolerance to physical exertion, i.e. Signs associated with any infectious process. Of great importance in recognizing the re-rheumatic attack, there are signs of insufficiency of blood circulation (both formerly and increasing and reinforcing) in the form of shortness of shortness of shortness of shortness of shortness of shortness of shortness, feelings of gravity in the right hypochondrium due to the increase in the liver.
- Consequently, the appearance or strengthening of signs of heart failure in a patient with the defect of the heart in many cases may be the result of a re-rheumatic attack.
Diagnostics
- OAK - an increase in ESR, neutrophilee with a shift to the left (leukocytosis only with a distinct lesion of the joints).
- Biochemical blood test - an increase in the blood content of fibrinogen, sialic acids, a CRP appears. ASLO is covered (antibodies to streptococcal antigens - anti-estrepsin o)
- X-ray studies of the heart and lungs are normal, however, with a serious flow of rheumlockarditis and signs of heart failure, heart dimensions can be increased
- ECG in part of patients detect signs of conductivity impairment (lengthening of the interval R-Q), as well as a decrease in the amplitude of the Tusque T (the so-called nonspecific changes in the teeth T).
Treatment
- Patients with an active rheumatic process are subject to hospitalization.
- Observe the bed mode to reduce the load on the cardiovascular system. Physiological shipments are allowed outside the bed.
- Diet number 10 - limited to the reception of the table salt, especially in the presence of signs of heart failure, as well as carbohydrates. It is important to observe the drinking mode: liquids are not more than 1.5 liters per day, and with pronounced heart failure, the reception of the liquid should be limited to 1 liter.
- Etiotropic treatment - ATB V / m Peniciline row (penicillin 2 000 000-4 000000 URS / SUT, ampicillin 2.0 g, oxacillin 2.0-3.0 g.,) Cephalosporin row (cefotaxim 1.0 2 times in Day), macrolides (Sumamed, azithromycin).
- NSAIDs: Acetylsalicylic acid, indomethacin, voltaren, etc. It should be remembered that when taking the NPP, dyspeptic disorders may be observed in the form of a decrease in appetite, nausea is sometimes the development of the stomach ulcers. The nurse must warn about this patient. These symptoms are largely reduced if medicines take after eating
6. Antihistamines: TAVEGIL, Supratine, Zoda, Loratadine, and T D
7. In severe cases, glucocorticoids: forenic
8. Patients with heart defects and an active rheumatic process in the presence of heart failure are prescribed diuretic drugs (furosemide, Veroshpirius) and cardiac glycosides (digoxin, stanfantine).
Prevention
Primary prophylaxis Hardening, sanitation of chronic infection foci (chronic tonsillitis, sinusitis, etc.) and the proper treatment of diseases caused by streptococcus (angina, aggravation of chronic tonsillitis).
Secondary prophylaxis It is to carry out seasonal or year-round bicyllinoprophylaxis. For this patients undergoing rheumatism, they put on dispensary accounting in the cardiorevmatological offices of the district polyclinic. Bicyllin is an antibiotic (from the penicillin group), which is injected intramuscularly once a week (Bicyllin-3) or once a month (Bicyllin-5); This is done to combat focal infection. In addition, in the autumn-spring period, such patients are also obtained within 2-3 weeks antheyshematic agents (usually in a half dose).
Potential problems: Development of heart failure (Mitral valve is most likely), the development of heart failure Plan of nursing interventions
Actions of a medical sister
- Observe the appointment of a doctor
- Control for diet
- Motor Motion Control
- Hemodynamic control: Hemodynamic: Hell, heart rate, chdd, r s, t, weighing 1 time in 3 days, control over diuresis
- Preparation for additional diagnostic methods
- Follow the sanitary condition of the chamber
- Interviews:
♦ on the meaning of the observance of labor, life, rest, nutrition;
♦ on the meaning of systematic biotillinoprophylaxis;
♦ on the meaning of systematic drug intake during the active phase of rheumatism;
♦ On the value of a periodic examination in a cardiorevmatology office
Determination of rheumatism toxic-immunological systemic inflammatory disease of the connective tissue with the preferential localization of the process in the cardiovascular system, developing in the persons predisposed to it due to infection of the β-hemolytic streptococcus group A rheumatism toxic-immunological systemic inflammatory disease of the connective tissue with the predominant localization of the process in the cardiovascular The vascular system developing in the persons predisposed to it due to infection of the β-hemolytic streptococcus group A
Rheumatism Etiology Etiology is currently convincingly proven that the emergence of rheumatism and its relapses are associated with the β-hemolytic streptococcus group A (tonsillitis, pharyngitis, streptococcal cervical lymphadenitis). Currently, it is convinmed that the occurrence of rheumatism and its relapses are associated with the β-hemolytic streptococcus group A (tonsillitis, pharyngitis, streptococcal cervical lymphadenitis). Pre-providing factors: supercooling, young age, heredity. Installed polygenic type of inheritance. The relationship of the disease is shown to inherit certain versions of Gaptoglobin, alloantgenic of limfocytes. Pre-providing factors: supercooling, young age, heredity. Installed polygenic type of inheritance. The relationship of the disease is shown to inherit certain versions of Gaptoglobin, alloantgenic of limfocytes.
Rheumatism Clinical symptoms Clinical symptoms 1. In typical cases, rheumatism, especially at the first attack, starts after 12 weeks. After transferred acute or exacerbation of chronic streptococcal infection (angina, pharyngitis). Then the disease enters the "latent" period (a duration of 1 to 3 weeks), characterized by asymptomatic flow or easy malaise, arthralgia, sometimes subfebrile body temperature. In the same period, it is possible to increase the ESP, the rise of the Titres of ASL-O, ASK, ASG. 2. The second period of the disease is characterized by a pronounced clinical picture, manifests itself with carditis, polyarthritis, other symptoms and changes in laboratory indicators.
Rheumatism of the rheumatic myocarditis clinic, endocarditis of a rheumatic myocarditis clinic, endocarditis diffuse myocarditis is characterized by: diffuse myocarditis is characterized by: 1. pronounced shortness of breath, 2. heartbeats, interruptions 3. Poles in the heart area, 4. The appearance of cough during exercise, in pronounced cases. Cardiac asthma and pulmonary swelling. 5. Increased body temperature
Rheumatism 6. Thromboembolic syndrome. 7. Strengthening systolic noise in the top of the heart and the appearance of diastolic noise in the top of the heart or aorta, which indicates the formation of heart defect. 8 Reliable sign of transferred endocarditis is the formed heart disease.
Rheumatism objectively objectively 1. Pulse frequent, often arrhythmical. 2. The boundaries of the heart are expanded, mainly to the left. 3. Tones are muted, the rhythm of gallop, arrhythmia, systolic noise in the top of the heart of the heart, first of a non-intensive nature is possible. 4. When developing stagnant phenomena in a small circle in the lower parts of the lungs, small-pushed wheels, attitudes, in a large circle increases and becomes a painful liver, may appear ascites and swells on the legs.
Rheumatism Rheumatic polyarthritis is more characteristic of primary rheumatism, its sharp synit. Rheumatic polyarthritis is more characteristic of primary rheumatism, its sharp synit. The main symptoms of rheumatic polyarthritis: the main symptoms of rheumatic polyarthritis: 1. Strong pain in large joints (symmetrically). 2. Punchiness, skin hyperemia in the joints of the joints. Sharp restriction of movements. 3. Flying character pain. 4. A quick stopping effect of non-steroidal anti-inflammatory drugs. 5. The absence of residual articular phenomena.
Rheumatism Rheumatic lung damage gives a picture of a pulmonary vasculitis and pneumonite (crepitium, fine-grained wheezes in the lungs, against the background of a reinforced pulmonary pattern of multiple sealing foci). The rheumatic lung damage gives a picture of a pulmonary vasculitis and pneumonite (crepitiation, small-pushed wheezes in the lungs, against the background of a reinforced pulmonary pattern of multiple sealing foci). Rheumatic pleurisy has ordinary symptoms. His distinctive feature is a fast positive effect of antipersum therapy. Rheumatic pleurisy has ordinary symptoms. His distinctive feature is a fast positive effect of antipersum therapy. Rheumatic kidney damage gives a jade painting with an isolated blade syndrome. Rheumatic kidney damage gives a jade painting with an isolated blade syndrome. Rheumatic peritonitis is manifested by abdominal syndrome (more often in children), characterized by pain in the abdomen, nausea, vomiting, sometimes tension of the abdominal muscles. Rheumatic peritonitis is manifested by abdominal syndrome (more often in children), characterized by pain in the abdomen, nausea, vomiting, sometimes tension of the abdominal muscles.
Rheumatism Neurorevimmatism is characterized by cerebral rheumovasculitis: neurorevimmatism is characterized by cerebral rheumovasculitis: 1. Encephalopathy (reduction of memory, headache, emotional lability, transient disorders of cranknot nerves). 2. Hypotalamic syndrome (vegetual-vascular dystonia, long-term subfebrile body temperature, drowsiness, thirst, vaginsular or sympatheadar crises). 3. Chorea (muscular and emotional weakness, hypercinesis), with the moore of heart defects are not formed.
Rheumatism of rheumatism of the skin and subcutaneous fiber rheumatism of the skin and subcutaneous tissue 1. manifests itself with ring-shaped erythema (pale pink, ring-shaped rashes in the body of the body, legs). 2. Subcutaneous rheumatic nodules (rounded, dense, painless nodules in the region of the exclusive surface of the knee, elbow, plusnefalast, plump-phalange joints).
Rheumism The diagnostic rule The presence of two large or one large and two small manifestations (criteria) and the proof of the previous streptococcal infection confirm the diagnosis of rheumatism. The presence of two large or one large and two small manifestations (criteria) and evidence of the previous streptococcal infection confirm the diagnosis of rheumatism.
Mitral valve failure Clinical picture. Clinical picture. 1. In the compensation stage, patients do not complaints and are capable of performing significant physical exertion. 2. When a reduction in the contractile function of the left ventricle and the development of pulmonary hypertension appear shortness and heartbeat during exercise. As the pulmonary hypertension increases, the attacks of cardiac asthma are possible. In some patients, the cough appears in this stage, dry or with a separation of a small amount of sputum mucosa (sometimes with blood admissions). 3. In the development of the right-hand deficiency, pain and severity in the field of right hypochondrium, edema of the legs appear.
Insufficiency of the Mitral Valve Auscultation Auscultation 1. Weakening of I Tone, often listened to the top III tone, accent and splitting of second tone over the pulmonary artery. 2. Systolic noise at the top is a soft, blowing or coarse with a musical tint, depending on the severity of the valve defect, is carried out in the axillary depression or the base of the heart. The noise is the most loud at the average degree of mitral insufficiency, less intense with insignificant or very pronounced. 3. In the position on the left side on the phase of the exhalation, the noise is listened better
Mitral valve deficiency Instrumental studies: Instrumental studies: 1. FKG: reducing the amplitude I, the appearance of Tone III, systolic noise associated with the i tone, permanent, expressed, sometimes focus of the second tone on the pulmonary artery. 2. EC: signs of hypertrophy of myocardium left atrium, left ventricle. 3. Heart X-ray: In the forefront of the projection, an increase in the 4th arc on the left circuit due to the left ventricular hypertrophy and the 3rd arc due to the left atrium hypertrophy (mitral heart configuration), the displacement of the contrasted esophagus on a large radius arc (more than 6 cm). 4. Echocardiogram: an increase in the amplitude of the movement of the front sash of the mitral valve, a noticeable absence of systolic closure, an expansion of the leftopean cavity and the left ventricle. Doppler-echocardiography reveals a turbulent blood flow into the left atrium, respectively, the degree of regurgitation.
Mitral stenosis Mitral stenosis narrowing of the left atrioventricular hole. Mitral stenosis narrowing of the left atrioventricular hole. Etiology: rheumatism. Etiology: rheumatism. The area of \u200b\u200bthe atrioventricular opening is normal 46 cm2, "Critical Square", at which noticeable hemodynamic disorders begin, 1 1.5 cm2. The area of \u200b\u200bthe atrioventricular opening is normal 46 cm2, "Critical Square", at which noticeable hemodynamic disorders begin, 1 1.5 cm2.
Mitral stenosis clinical symptoms. Clinical symptoms. 1. In the compensation period there is no complaints. 2. In the period of decomptionation of cough with blood in sputum, shortness of breath, heartbeat, interruptions and pain in the heart of the heart, swelling on the legs, with a pronounced decompensation of pain in the field of right hypochondrium, an increase in abdomen.
Mitral stenosis when inspection when inspection 1. Cyanotic jack of cheeks in the form of a "butterfly". 2. Akricyanosis, in children in poor physical development, infantilism. 3. "Heart hump" (due to hypertrophy and dilatation of the right ventricle). 4. Pulsation in epigastrics at the expense of the right ventricle.
Mitral stenosis Palpation - on the top of the heart The diastolic jitter "Cat Murly". Palpation - on the top of the heart diastolic jitter "Cat purr". Percussion Increasing borders of Ut Up (LP) and Right (PJ). Percussion Increasing borders of Ut Up (LP) and Right (PJ). Auscultation - clapping I tone, click opening of the mitral valve, the rhythm of the "quail" (clapping I tone, normal II tone, the opening of the mitral valve), accent and split the tone of the pulmonary artery, protodiastolic (less than mezodiastic) and presetolytic noise. Auscultation - clapping I tone, click opening of the mitral valve, the rhythm of the "quail" (clapping I tone, normal II tone, the opening of the mitral valve), accent and split the tone of the pulmonary artery, protodiastolic (less than mezodiastic) and presetolytic noise. With significant pulmonary hypertension over the pulmonary artery, the diastolic noise of the style (relative failure of pulmonary artery valves) can be determined. With significant pulmonary hypertension over the pulmonary artery, the diastolic noise of the style (relative failure of pulmonary artery valves) can be determined.
Mitral Stenosis ECG: Hypertrophy of the left atrium, Hypertrophy of the right ventricular ECG: Hypertrophy of the left atrium, Hypertrophy of the right ventricle F to r: At the top of the heart, a large amplitude of the Tone I and the opening of the opening of 0.080.12 ° C after type II, the lengthening of the QI interval tone to 0.080, 12 C, protodiastolic and preseign noise; An increase in amplitude and splitting of second tone on the pulmonary artery. F to g: At the top of the heart, a large amplitude I of tone and a clock opening by 0.080.12 ° C after tone, the elongation of the interval Qi tone to 0.080.12 ° C, protodiastolic and presets; An increase in amplitude and splitting of second tone on the pulmonary artery. Heart X-ray: smoothing the waist of the heart, blowing the second and third arcs on the left contour due to the pulmonary artery and hypertrophied left atrium, the deviation of the contrasted esophagus along the arc of a small radius (less than 6 cm). Heart X-ray: smoothing the waist of the heart, blowing the second and third arcs on the left contour due to the pulmonary artery and hypertrophied left atrium, the deviation of the contrasted esophagus along the arc of a small radius (less than 6 cm). Echocardiography: Unidirectional movement of the front and rear flaps of the mitral valve forward (normally the rear flap in the diastole is shifted by the stop), the speed of early diastolic closure of the front sash and the amplitude of its movement is reduced, the valve thickening, the expansion of the right ventricular cavity. Echocardiography: Unidirectional movement of the front and rear flaps of the mitral valve forward (normally the rear flap in the diastole is shifted by the stop), the speed of early diastolic closure of the front sash and the amplitude of its movement is reduced, the valve thickening, the expansion of the right ventricular cavity.
34
Aorta valve deficiency Maximum noise is located in the II intercole on the right of the sternum. Maximum noise is located in the second intercostal After the second tone of the decreasing nature of the decreasing nature, the entire diastole (holodiastic) is usually occupied. It usually takes the entire diastole (holling).
Heart boundaries in the stenosis of the mouth of aorta (compensation stage). Change of heart boundaries in the stenosis of the mouth of the aorta (decompensation stage). Change of heart boundaries in the stenosis of the mouth of the aorta (decompensation stage). Rice of the border of the heart during the stenosis of the mouth of the aorta (stage of compensation). Ri £ change the boundaries of the heart during the stenosis of the aorta's mouth (stage of decompensation).
