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"lead": "«Каротидный шум» — это неправильный звук (систолический шум) выслушиваемый стетоскопом на шее в проекции сонных артерий из-за сужения сонной артерии, или различие в пульсе между двумя сторонами шеи. Он говорит о высоком вероятности поражения сонной артерии. Каротидный шум — симптом атеросклероза. Он скорее является прогностическим признаком инфаркта миокарда, нежели инсульта. Хотя шум и указывает на повышенный риск развития инсульта, последний может произойти как на стороне каротидного шума, так и на противоположной стороне головного мозга.",
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"lead": "Наруше́ние созна́ния — состояние расстроенного сознания, синдромы его выключения (кома, сопор, оглушение) или помрачения (онейроид, делирий, сумеречное состояние сознания). Полноценное функционирование сознания предполагает состояние бодрствования, обусловленное полноценной реализацией когнитивной функции полушарий головного мозга и их взаимоотношений с пробуждающими механизмами ретикулярной формации, распространение ядер и проводящих путей которой обнаружены в диэнцефальной области, среднем мозге, варолиевом мосте и продолговатом мозге.\r\n\r\nРетикулярная активирующая система представляет собой функциональное, а не морфологическое понятие и располагается вдоль центральной оси диэнцефальной области и верхних отделов ствола мозга. Это система получает афферентные импульсы из многих соматических, висцеральных, слуховых, и зрительных сенсорных проводящих путей, направляет их в ретикулярное ядро зрительного бугра, из которого, в свою очередь, активация распространяется по всем отделам коры головного мозгаНарушение сознания является проявлением дисфункции полушарий, верхних отделов ствола головного мозга, или и той, и другой области одновременно. Так, местное поражение супратенториальных структур может носить распространенный характер, а может, вызывая отёк, смещать мозговые структуры, приводя к транстенториальной герниации, сдавлению диэнцефальных отделов головного мозга и нарушению функции диэнцефальной активирующей системы.\r\n\r\nПервичные субтенториальные процессы (ствола мозга и мозжечка) могут сдавливать или непосредственно повреждать ретикулярную активирующую систему между средними отделами варолиевого моста и диэнцефальной областью.\r\nМетаболические или инфекционные заболевания могут оказывать угнетающее воздействие на функцию полушарий и ствола головного мозга посредством патологического содержания компонентов крови или прямого токсического эффекта.\r\nНарушение сознания может наблюдаться также при нарушении мозгового кровообращения (синкопы и инфаркт) или при изменении биоэлектрической активности мозга (эпилепсия). Неадекватный мозговой кровоток и химический дисбаланс крови может также вызывать нарушение электрической активности мозга.\r\nСотрясение головного мозга и психологические расстройства вызывают нарушение сознания без видимых структурных изменений мозга.",
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"slug": "gematologiya",
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},
"code": "J18",
"name": "Пневмония",
"icd_name": "Пневмония без уточнения возбудителя",
"gender": 0,
"age_min": 0,
"age_max": 100,
"cause": [
3
],
"periodicity": 1,
"slug": "j18_pnevmoniya",
"lead": "Острое инфекционно-воспалительное заболевание легких с вовлечением всех структурных элементов легочной ткани с обязательным поражением альвеол и развитием в них воспалительной экссудации",
"description": "Пневмония не описывает какую-то одну специфичную инфекцию. То, что врачи называют пневмонией, может иметь более 50 различных причин. К развитию заболевания могут приводить бактерии, вирусы, грибы и химические раздражители.",
"etiology": "<p align=\"justify\">Среди причин, вызывающих пневмонию, на первом месте стоит бактериальная инфекция. Чаще всего возбудителями пневмонии являются:</p>\r\n<ul>\r\n<li>грамположительные микроорганизмы: пневмококки (от 40 до 60%), стафилококки (от 2 до 5%), стрептококки (2,5%);</li>\r\n<li>грамотрицательные микроорганизмы: палочка Фридлендера (от 3 до 8%), гемофильная палочка (7%), энтеробактерии (6%), протей, кишечная палочка, легионелла и др. (от 1,5 до 4,5%);</li>\r\n<li>микоплазмы (6%);</li>\r\n<li>вирусные инфекции (вирусы герпеса, гриппа и парагриппа, аденовирусы и т. д.);</li>\r\n<li>грибковые инфекции.</li>\r\n</ul>\r\n<p align=\"justify\">Также пневмония может развиваться вследствие воздействия неинфекционных факторов: травм грудной клетки, ионизирующего излучения, токсических веществ, аллергических агентов.</p>\r\n<p align=\"justify\">К группе риска по развитию пневмонии относятся пациенты с застойной сердечной недостаточностью, хроническими бронхитами, хронической носоглоточной инфекцией, врожденными пороками развития легких, с тяжелыми иммунодефицитными состояниями, ослабленные и истощенные больные, пациенты, длительно находящиеся на постельном режиме, а также лица пожилого и старческого возраста.</p>\r\n<p align=\"justify\">Особо подвержены развитию пневмонии курящие и злоупотребляющие алкоголем люди. Никотин и пары алкоголя повреждают слизистую оболочку бронхов и угнетают защитные факторы бронхопульмональной системы, создавая благоприятную среду для внедрения и размножения инфекции.</p>",
"pathogenesis": "<p>Длительность инкубационного периода различна, зависит от возбудителя и организма человека (состояние иммунитета, наличие сопутствующих заболеваний) и составляет от 1-3 дней при типичных формах и до 2-3 недель при пневмониях (<a href=\"/symptom/vospalenie/\" title=\"Перейти на страницу симптома воспаление\">воспаление</a> легких), вызванных атипичными возбудителями (микоплазма, легионелла, хламидия).</p>\r\n<full></full>\r\n<p>1. Проникновение возбудителей пневмонии в респираторные отделы легких бронхогенным (наиболее часто), гематогенным (при сепсисе, эндокардите трехстворчатого клапана, септическом тромбофлебите тазовых вен, общеинфекционных заболеваниях), per continuinatem (непосредственно из соседних пораженных органов, например, при абсцессе печени), лимфогенным путями с последующей адгезией на эпителиальных клетках бронхопульмональной системы. При этом пневмония развивается лишь при нарушении функции системы местной бронхопульмональной защиты, а также при снижении общей реактивности организма и механизмов неспецифической защиты.</p>\r\n<p>2. Развитие под влиянием инфекции локального воспалительного процесса и его распространение по легочной ткани.</p>\r\n<p>Часть микрорганизмов (пневмококк, клебсиелла, кишечная палочка, гемофильная палочка) продуцируют вещества, усиливающие сосудистую проницаемость, в результате пневмония, начинаясь с небольшого очага, далее распространяется по легочной ткани в виде «масляного пятна» через альвеолярные поры Кона. Другие микроорганизмы (стафилококки, синегнойная палочка) выделяют экзотоксины, разрушающие легочную ткань, в результате чего образуются очаги некроза, которые, сливаясь, формируют абсцессы. Большую роль в развитии пневмонии играет продукция лейкоцитами цитокинов (ИЛ-1, 6, 8 и др.), стимулирующих хемотаксис макрофагов и других эффекторных клеток.</p>\r\n<p>3. Развитие сенсибилизации к инфекционным агентам и иммуно-воспалительных реакций (при гиперергической реакции организма развивается долевая пневмония, при нормо — или гипергической – очаговая пневмония).</p>\r\n<p>4. Активация перекисного окисления липидов и протеолиза в легочной ткани, оказывающих непосредственное повреждающее влияние на легочную ткань и способствующих развитию в ней воспалительного процесса.</p>",
"diagnostics": "<p align=\"justify\">При диагностике пневмонии решаются сразу несколько задач: дифференциальная диагностика воспаления с другими легочными процессами, выяснение этиологии и степени тяжести (осложнений) пневмонии.</p>\r\n<p align=\"justify\">Пневмонию у пациента следует заподозрить на основании симптоматических признаков: быстрого развития лихорадки и интоксикации, кашля.</p>\r\n<p align=\"justify\">При физикальном исследовании определяется <a href=\"/symptom/otek_tkaney/\" title=\"Перейти на страницу симптома Отек тканей\">уплотнение</a> легочной ткани (на основании перкуторного притупления легочного звука и усиления бронхофонии), характерной аускультативной картины - очаговых, влажных, мелкопузырчатых, звучных хрипов или крепитации.</p>\r\n<full></full>\r\n<p>Диагностика пневмонии.</p>\r\n<p>Рентгенография органов грудной клетки – важнейший метод диагностики пневмонии.</p>\r\n<p>В начальной стадии пневмонии – усиление легочного рисунка пораженных сегментов.</p>\r\n<p>В стадии уплотнения – интенсивное затемнение участков легкого, охваченных воспалением (участки инфильтрации легочной ткани); при долевой пневмонии тень однородка, гомогенна, в центральных отделах более интенсивная, при очаговой пневмонии воспалительная инфильтрация в виде отдельных очагов.</p>\r\n<p>В стадии разрешения уменьшаются размеры и интенсивность воспалительной инфильтрации, постепенно она исчезает, структура легочной ткани восстанавливается, но корень легкого длительное время может оставаться расширенным.</p>\r\n<p>Лабораторный синдром воспаления: лейкоцитоз, свдиг лейкоцитарной формулы влево, токсическая зернистость нейтрофилов, лимфопения, эозинопения, увеличение СОЭ в ОАК, повышение содержания a2- и g-глобулинов, сиаловых кислот, серомукоида, фибрина, гаптоглобина, ЛДГ (особенно 3-ей фракции), С-реактивного белка в БАК.</p>\r\n<p> </p>",
"treatment": "<p>Первое, что нужно сделать, — это скорейшим образом назначить больному этиотропную терапию. Она проводится согласно общепринятым стандартам антибактериальной терапии пневмоний. Если выбранная терапия эффективна, то ее продолжают обычно на протяжении 7-10 дней. Но если на протяжении 3-х дней лечение не оказывает должного эффекта, фиксируется отсутствие положительной динамики, появляются различные осложнения, то переходят на альтернативную схему лечения. Рекомендуемые схемы проведения антибактериальной терапии: Нетяжелые пневмонии у пациентов в возрасте до 60 лет без сопутствующих заболеваний. Препараты выбора: антибиотики для перорального применения (аминопенициллины, макролиды); альтернативные препараты: доксициклин, респираторные фторхинолоны. Пневмонии у пациентов старше 60 лет с сопутствующими заболеваниями. Препараты выбора: защищенные аминопенициллины для перорального применения +/- макролиды, цефалоспорины I поколения для перорального применения; альтернативные препараты: респираторные фторхинолоны. Клинически тяжелые пневмонии независимо от возраста больных. Препараты выбора: цефалоспорины III поколения для парентерального применения + макролиды для парентерального применения; альтернативные препараты: фторхинолоны для парентерального применения. Когда состояние больного стабилизируется и происходит регресс клинической симптоматики, на первое место выходят физиолечение, массаж, лечебная физкультура, применение бронхолитических препаратов. Всегда следует помнить, что если летальность больных с нетяжелой внебольничной пневмонией составляет порядка 5%, то аналогичные показатели среди лиц пожилого и старческого возраста с тяжелым течением внебольничной пневмонии составляют порядка 30%.</p>",
"prevention": "<ul class=\"list list-description\">\r\n<li>Вакцинация (пневмококковой, гриппозной вакцинами, вакциной против гемофильной палочки). Особенно важна вакцинация лицам, относящимся к « группе риска» — пожилым, пациентам с нарушением функции системы иммунитета, страдающим хроническими заболеваниями легких, сердечно-сосудистой системы, сахарным диабетом, проживающим в домах престарелых и находящимся на постоянном уходе (диализ).</li>\r\n<li>Оптимальное время вакцинации: октябрь – середина ноября. В дальнейшем эффективность вакцинации значительно уменьшается, поскольку резко возрастает вероятность того, что организм уже контактировал с активизирующимися в это время вирусами и бактериями, а следовательно, не сможет обеспечить достаточный иммунный ответ даже после прививки.</li>\r\n<li>Своевременное лечение вирусных инфекций (ОРВИ).</li>\r\n<li>Устранение очагов хронической инфекции.</li>\r\n<li>Исключение переохлаждений.</li>\r\n</ul>\r\n<p> </p>",
"clinical_picture": "<p>«Типичная» пневмония характеризуется резким подъёмом температуры, кашлем с обильным выделением гнойной мокроты и, в некоторых случаях, плевральной боли. При исследовании: укорочение перкуторного звука, жёсткое дыхание, усиленная бронхофония, усиленное голосовое дрожание, сначала сухие, а затем влажные, крепитирующие <a href=\"/symptom/hripy/\" title=\"Перейти на страницу симптома Хрипы\">хрипы</a>, затемнение на рентгенограмме. Такую пневмонию вызывают Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae.</p>\r\n<full></full>\r\n<p><br />Легочные проявления пневмонии:</p>\r\n<ul>\r\n<li><a href=\"/symptom/kashel/\" title=\"Перейти на страницу симптома Кашель\">кашель</a> – вначале сухой, у многих в 1-ые сутки в виде частого покашливания, на 2-ые сутки <a href=\"/symptom/kashel/\" title=\"Перейти на страницу симптома Кашель\">кашель</a> с трудноотделяемой мокротой слизисто-гнойного характера; у больных долевой пневмонией часто появляется «ржавая» <a href=\"/symptom/vlazhnyy_kashel/\" title=\"Перейти на страницу симптома Влажный кашель\">мокрота</a> в связи с появлением в ней большого количества эритроцитов.</li>\r\n<li>боли в грудной клетке – наиболее характерны для долевой пневмонии, обусловлены вовлечением в процесс плевры (плевропневмония) и нижних межреберных нервов. Боль появляется внезапно, она достаточно интенсивная, усиливается при кашле, дыхании; при выраженной боли отмечается отставание соответствующей половины грудной клетки в акте дыхания, больной «щадит ее» и придерживает рукой. При очаговой пневмонии боль может быть слабо выраженной или отсутствовать.</li>\r\n<li><a href=\"/symptom/odyshka/\" title=\"Перейти на страницу симптома Одышка\">одышка</a> – ее выраженность зависит от протяженности пневмонии; при долевой пневмонии может наблюдаться значительное тахипноэ до 30-40 мин, лицо при этом бледное, осунувшееся, с раздувающимися при дыхании крыльями носа. <a href=\"/symptom/odyshka/\" title=\"Перейти на страницу симптома Одышка\">Одышка</a> нередко сочетается с ощущением «заложенности в груди».</li>\r\n</ul>\r\n<p>Физикальные признаки локального легочного воспаления:</p>\r\n<ul>\r\n<li>притупление (укорочение) перкуторного звука соответственно локализации воспалительного очага (всегда четко определяется при долевой и не всегда выражено при очаговой пневмонии)</li>\r\n<li>усиление голосового дрожания в связи с уплотнением легочной ткани над очагом поражения (при долевой пневмонии)</li>\r\n<li><a href=\"/symptom/krepitaciya/\" title=\"Перейти на страницу симптома Крепитация\">крепитация</a>, выслушиваемая над очагом воспаления – напоминает мелкий треск или звук, который выслушивается, если растирать пальцами пучок волос около уха; обусловлена разлипанием во время вдоха стенок альвеол, пропитанных воспалительным экссудатом; выслушивается только во время вдоха и не слышна во время выдоха</li>\r\n<li>Для начала пневмонии характерна crepitatio indux, она негромкая, выслушивается на ограниченном участке и как-будто доносится издалека; для разрешения пневмонии характерна crepitatio redux, она громкая, звучная, выслушивается на более обширном участке и как бы непосредственно над ухом. В разгар легочного воспаления, когда альвеолы заполнены воспалительным экссудатом, <a href=\"/symptom/krepitaciya/\" title=\"Перейти на страницу симптома Крепитация\">крепитация</a> не прослушивается.</li>\r\n<li>мелкопузырчатые <a href=\"/symptom/hripy/\" title=\"Перейти на страницу симптома Хрипы\">хрипы</a> в проекции очага воспаления – характерны для очаговой пневмонии, являются отражением сопутствующего бронхопневмонии локального бронхита</li>\r\n<li>изменение везикулярного дыхания – в начальной стадии и фазе разрешения пневмонии везикулярное дыхание ослаблено, а при долевой пневмонии в фазе выраженного уплотнения легочной ткани везикулярное дыхание не прослушивается.</li>\r\n<li>бронхофония – усиление <a href=\"/symptom/sluhovye_gallyucinacii/\" title=\"Перейти на страницу симптома Слуховые галлюцинации\">голоса</a> больного, выслушиваемого через грудную клетку (больной шепотом произносит «раз, два, три») – наблюдается в фазе значительного уплотнения легочной ткани при долевой пневмонии</li>\r\n<li>бронхиальное дыхание – выслушивается при наличии обширного участка уплотнения легочной ткани и сохраненной бронхиальной проводимости.</li>\r\n<li>шум трения плевры – определяется при плевропневмонии</li>\r\n</ul>\r\n<p>Внелегочные проявления пневмонии:</p>\r\n<ul>\r\n<li><a href=\"/symptom/vysokaya_temperatura_38-42/\" title=\"Перейти на страницу симптома Высокая температура 38-42° \">лихорадка</a>, ознобы – долевая пневмония начинается остро, внезапно появляется интенсивная <a href=\"/symptom/bol_v_grudi/\" title=\"Перейти на страницу симптома Боль в груди \">боль в грудной клетке</a>, усиливающаяся при дыхании, наблюдаются <a href=\"/symptom/oznob/\" title=\"Перейти на страницу симптома Озноб\">озноб</a>, <a href=\"/symptom/vysokaya_temperatura_38-42/\" title=\"Перейти на страницу симптома Высокая температура 38-42° \">повышение температуры</a> до 39 °С и выше; очаговая пневмония начинается постепенно, <a href=\"/symptom/vysokaya_temperatura_38-42/\" title=\"Перейти на страницу симптома Высокая температура 38-42° \">повышение температуры</a> постепенное, как правило, не выше 38,0-38,5 °С, <a href=\"/symptom/oznob/\" title=\"Перейти на страницу симптома Озноб\">озноб</a> не закономерен.</li>\r\n<li>синдром интоксикации – общая <a href=\"/symptom/slabost/\" title=\"Перейти на страницу симптома Слабость\">слабость</a>, <a href=\"/symptom/utomlyaemost/\" title=\"Перейти на страницу симптома Утомляемость\">снижение работоспособности</a>, <a href=\"/symptom/potlivost/\" title=\"Перейти на страницу симптома потливость\">потливость</a> (чаще ночью и при незначительной физической нагрузке), снижение или полное <a href=\"/symptom/anoreksiya/\" title=\"Перейти на страницу симптома Анорексия\">отсутствие аппетита</a>, миалгии, арталгии на высоте лихорадки, <a href=\"/symptom/golovnaya_bol/\" title=\"Перейти на страницу симптома Головная боль\">головная боль</a>, при тяжелом течении – <a href=\"/symptom/dezorientaciya/\" title=\"Перейти на страницу симптома Дезориентация\">спутанность сознания</a>, <a href=\"/symptom/bred/\" title=\"Перейти на страницу симптома Бред\">бред</a>. При тяжелом течении долевой пневмонии возможна <a href=\"/symptom/zheltuha/\" title=\"Перейти на страницу симптома Желтуха\">желтуха</a> (из-за нарушения функции печени при выраженной интоксикации), кратковременная <a href=\"/symptom/diareya/\" title=\"Перейти на страницу симптома Диарея\">диарея</a>, протеинурия и цилиндрурия, <a href=\"/symptom/obmetyvanie_gub/\" title=\"Перейти на страницу симптома Обметывание губ\">герпес</a>.</li>\r\n</ul>\r\n<p> </p>",
"image": null,
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"standard_type": 1,
"danger": 51,
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{
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