HSN, only to experts

[Olga]

I, the student 5 courses MGMSU. On a cycle "therapy" I conduct the patient. Therapy of the doctor seems to me not correct. Certainly, I am difficult to ask consultation to the patient on distance, but very much obespokoina its or his status. My patient suffers a bronchial asthma of 12 years. As a result of development DN + postinfarction or postmyocardial infarction karioskleroz has developed HSN, which patient corrected or adjusted two tablets of Furosemidum in day when edemas and a dyspnea or short wind accrued or increased. Before entering in hospital there were pains in the field of heart in this connection has been hospitalized. The patient has come to hospital itself, and in 2 weeks does not move on chamber, does not sleep - laying chokes, edemas on all body, and an anticnemion are not simply increased in sizes, and such oshchushchunie, that the skin just about will burst, except for that an anticnemion very wet - on them is direct struitsja water. A BP at it or him of 100/70 mm rt st, the CARDIAC CONTRACTIONS RATE 60 in mines, CHD 40 in minutes Preparations, naznachenye the doctor: digoxin, Furosemidum, asparkam, Nitrosorbidum, Cefazolinum, Cordiaminum, Polyglucinum. The patient receives during a week every day Polyglucinum then to him becomes worse. I heard, that at an overdosage of Polyglucinum, fibers of this preparation can leave vessels in a tissue and draw on themselves water, then the patient very difficultly deduce or remove from this status. Besides therapy by Sodium nitritums which expand or dilate peripheric vessels, lowering pressure seems to me not opravdanoj, reducing (as it seems to me at this patient) intimate or cardiac emission. Contact to the attending physician on this question is useless. I can something I confuse and is not competent enough, and my report is a little bit emotional, but it is difficult to me to look as this person dies. Here something is wrong so quickly decompensate HSN cannot - literally 2 weeks and without a serious pathology of heart. A bronchial asthma at the patient as in a under control status. If you will help or assist me - I shall be grateful. It seems to me, that it is better to ask silly questions during study, than then bashfully to kill patients. In advance thanks.

[well]

The dear Olga, the best will be if all of you will find an opportunity to discuss this problem with lech the doctor, or with manager of unit. For a cardiomyopathy (vidat about her also there is a speech), any volumetric overloads and if solutions they should korregirovatsja diuretic, or are entered by inotropic preparations are dangerous. Sodium nitritums often are applied at SN as I reduce a preload and by that increase or enlarge intimate or cardiac emission.
You have written to nothing about sokratitelnoj functions of a myocardium (EhoKG). For comprehension it is necessary to know volumes, FI, a status of the valval apparatus of heart.

[VOLKON]

Hello, Olga!

It is very good, that you take to heart sufferings of patients. But, I completely agree with the previous author what correctly to estimate or appreciate a status of the patient under your description difficultly. You write, that the patient does not have serious pathology of heart mentioning thus, that at it or him a postinfarction or a postmyocardial infarction cardiosclerosis. It in fact very serious pathology. Considering pains before entering in a hospital it is possible to suspect a repeated myocardial infarction of a thorax. You have not written, whether there is at the patient a disturbance of an intimate or a cardiac rhythm, a ciliary arrhythmia, for example. Eventually, you in fact conduct this patient not one and live not in deaf or indistinct village. For certain, you have a teacher. Discuss a situation with it or him.

[Olga]

Thanks for answers and participation. Today I had on duty day in this unit and I have found an opportunity to communicate and with the attending physician and to ask consultation of the teacher. I have understood in general also all have realized. Once again many thanks, I hope for further your help on various questions, I shall try to be less emotional and more concrete. Yours faithfully, Olga.

[VOLKON]

CHao!

[Olga]

Hello! And nevertheless... Only on 3 week of stay of the patient in a hospital have made the ECHO-KG.
The aorta is condensed, not expanded - Ao 3,2 (and *925; up to 3,7). The aortal valve: cusps are condensed, amplitude of disclosing of cusps Ak of 1,6 sm (and *925; 1,3-2,1), separation of cusps in a diastole is not revealed. Vegetations are not found out.
The left auricle: 4,0 sm (N up to 4,0)
The cavity of a left ventricle is not expanded - KDR 3,9 (N up to 5,5), KSR 1,4 sm (and *925; 3,8).
Local contractility normal.
Interventricular septum: utolshchena - TMZHP in a diastole of 1,5 sm (and *925; up to 1,1)
Back wall of a left ventricle: utolshchena - TZSLZH in a diastole 1,2 (and *925; up to 1,1)
The mitral valve: the forward cusp moves M is-shaped or -shapedly, a back cusp - in an antiphase. prolaps it is found out, a forward cusp 4, a back cusp 5.
The right auricle is increased 5,2 h 4,9. The Right ventricle: it is expanded, the bearing or taking out tract is expanded 5,4 sm (N up to 3,0). Thickness of a free wall of 0,6 sm (N up to 0,5).
The three-cuspidate valve: cusps are not condensed, prolaps is not found out. Vegetations are not found out. Separation of leaves of a pericardium is not revealed.
The conclusion: visualization is complicated because of gravity of a status of the patient. The aorta is condensed, not expanded. AK it is condensed. The right departments are considerably expanded. A hypertrophy of a myocardium of both ventricles. Local contractility is not changed.
13.05.03 on an electrocardiogram sinusovaja a tachycardia - 110. Deviation or rejection EOS to the right, blockade of the right leg or pinch of a ventriculonector, an overload of the right auricle, a hypertrophy of the right departments of heart. Change of a myocardium with decrease of blood supply - possibly -cicatrical changes of a myocardium of a forward wall (the patient denies an infarct in the anamnesis).
As a result of week treatment (described above) 22.05.03 on an electrocardiogram a rhythm from ao-bond with the subsequent exaltation of auricles. Changes of a myocardium without essential dynamics or changes of the CARDIAC CONTRACTIONS RATE 70.
The teacher has explained to me, that Polyglucinum in such quantities or amounts pour for maintenance at sick pressure. Pressure at the patient and up to and as a result injections 90/50, and edemas more increasing or more and more and more. Please, explain, what for to load sick with a liquid, if at it or him stagnation on the big circle? I understand, what at the patient most likely a hypovolemia, but can try to clean or remove a liquid from tissues and thus to restore OTSK? Vazodilatatory at pulmonary heart reduce an available pulmonary hypertensia a little, but can essentially reduce gas exchange and cause or call a systemic arterial hypotension. In that case what for Sodium nitritums are appointed or nominated? In fact the left ventricle is not overloaded (I am mistaken?) Intimate or Cardiac glycosides can cause or call arrhythmias and are shown at pulmonary heart if the left ventricular failure, a tachyarrhythmia (fibrillation of auricles), than obuslovseno their purpose or appointment here has joined? On target procedures was not, the patient holds legs or foots all time in the raised status and approves or confirms, that the diuresis has increased also edemas have decreased, and subjectively feels itself better. This subject for me complex or difficult, can I something I do not understand, explain please what should be the approach to such patient. In the book all is clear, and in practice - is not present.
02.05 on an electrocardiogram the sinoatrial rate is restored. The CARDIAC CONTRACTIONS RATE 90. Retardation AV of conduction.
The bronchial asthma (there is no atopy), and HOBL seems to me, that at the patient not, under my insisting he has stopped to smoke (15.05) I has appointed or nominated to patient Ipratropija Bromidum and since there is an insignificant tussis with poor or scanty separated a purulent sputum still Acetylcysteinum and Cefazolinum; an oxygenotherapy. Well and, certainly, has left diuretics. It is the correct approach? In advance thanks for attention.
VOLKON, why "CHao"? To Me dialogue with you is pleasant;).

[Olga]

Yes, the doctor, I have understood, probably really good-bye. I and Xomo you have got? Forgive or excuse, please. While. Success. P.S. In fact it is valid cherezvychajno difficultly to advise on distance how you have ventured it? Or the purpose of this forum - advertising of the med.tsentrov? I Wish you rising of your incomes. Sincerely yours Olga.

[VOLKON]

Hello, Olja!

I hope, that you are not familiar with it or this XOMO, differently I would cease to respect with you. On the Internet always it is a lot of shizikov. It seems to me, that you do not have not enough dialogue. That do you want? That I have told or said, that treatment which is spent by your doctors, wrong. And you, having referred to opinion of the virtual doctor, would argue with your doctors? You in fact have written, that to the patient it became easier also it means, that therapy was correct. From your description to me all the same remains obscure, that has served as the reason of a decompensation. There can be it there was a thromboembolism of fine branches of a pulmonary artery or an infarct of a right ventricle? In fact, apparently, the situation has developed quickly enough. And concrete treatment very much often can not coincide that is written in the textbook. And absolutely you are not right that my presence at this forum is connected with advertising. To me yet has not got any patient who could come to me on internal consultation. I hope, that your judgements about people will change for the better.

[Olga]

Well, well, there is I - zakompleksovanyj the teenager living on the Internet from shortage of dialogue (Ha, you would see me!)? Speak, that Piterburzhskaja the medical school still keeps, and at us, in HIGH SCHOOL full disorder! The Teacher from 5 put hours spends with us 20 minutes, - marks or celebrates present in the beginning and in the extremity or end of employment or occupation. Tried something to do or make with it or this - all group excruciatingly and longly could not pass a test. Young teachers at once speak - the competition is not necessary to us, and without you affairs on a throat. And the professor on surgery has told or said, that will be engaged with students if at it or him them will be only two and those will pay on 40 000 dollars, as in the West. In the given concrete unit divergences on a category 3 (for weeks treated from HPN, and has died of a lung fever, not very much an oar, the truth are frequent?) The Internet I use often for extraction new honey. Information. As not to that to ask interesting questions, has decided to try to make it at a forum - before and did not represent, as it is possible to advise the patient not to time not seeing it or him. Well, the invention was silly, but thoughts pure or clean. And to you, the doctor, all the same I wish the most best incomes since by some your publications, you are not satisfied by the trade. And I concern to people initially most in the best way, differently would not spend so much forces for training of so ungrateful or thankless and humane trade. Farewell.