Молодежный инновационный вестникМолодежный инновационный вестник2415-7805Федеральное государственное бюджетное образовательное учреждение высшего образования "Воронежский государственный медицинский университет имени Н.Н. Бурденко" Министерства здравоохранения Российской Федерации6709UnclassifiedDIFFICULTIES IN EARLY REHABILITATION OF THE PATIENT THE RECOVERY PERIOD OF A CEREBRAL INFARCTION AGAINST THE BACKGROUND OF A POSTPONED CORONAVIRUS INFECTIONBedirovMark Dzhalatovichbedirovmark@inbox.ruhttps://orcid.org/0000-0003-1818-07191405202110S12572602603202112042021Copyright © 2021, Молодежный инновационный вестник2021<p><span style="font-weight: 400;">Relevance. The current situation in world medicine is due to the struggle</span></p>
<p><span style="font-weight: 400;">with a new coronavirus infection and its complications. Models of the pathogenetic effect of coronavirus 2 acute respiratory syndrome (SARS-CoV-2) in the new coronavirus infection 2019 (COVID-19) on the brain indicate the possibility of both direct and indirect damage. Stroke or acute cerebrovascular accidents are the most common cause of disability and death worldwide. Stroke is also one of the most common complications of a new coronavirus infection from</span></p>
<p><span style="font-weight: 400;">nervous system.</span></p>
<p><span style="font-weight: 400;">Purpose. To study the features of the course of ischemic stroke and the features of rehabilitation in the early recovery period in patients with COVID-19 disease</span></p>
<p><span style="font-weight: 400;">Methods. The analysis of a patient with stroke by ischemic type, developed against the background of bacterial</span></p>
<p><span style="font-weight: 400;">viral pneumonia of mild severity in a patient with COVID-19.</span></p>
<p><span style="font-weight: 400;">Results. Treatment, methods and</span></p>
<p><span style="font-weight: 400;">the results of early rehabilitation, as well as the prognosis of the disease.</span></p>
<p><span style="font-weight: 400;">Conclusion. The considered case of a complicated course</span></p>
<p><span style="font-weight: 400;">a new coronavirus infection with the development of ischemic stroke,</span></p>
<p><span style="font-weight: 400;">proved the effectiveness of the successive management of the patient in</span></p>
<p><span style="font-weight: 400;">specialized centers for the treatment of COVID-19 and acute cerebrovascular accidents and high economic efficiency, the social significance of intensive multi-vector treatment and rehabilitation from the very</span></p>
<p><span style="font-weight: 400;">onset of the disease</span></p>coronavirus infection, cerebrovascular accident, complications,
neurogenic bladder, rehabilitation.Коронавирусная инфекциянарушение мозгового кровообращенияосложнениянейрогенный мочевой пузырьреабилитация.<p><span style="font-weight: 400;">Relevance</span></p>
<p><span style="font-weight: 400;">The current situation in world medicine is due to the struggle</span></p>
<p><span style="font-weight: 400;">with a new coronavirus infection and its complications. Models of the pathogenetic effect of coronavirus 2 acute respiratory syndrome (SARS-CoV-2) in the new coronavirus infection 2019 (COVID-19) on the brain indicate the possibility of both direct and indirect damage. Stroke or acute cerebrovascular accidents are the most common cause of disability and death worldwide. Stroke is also one of the most frequent complications of a new coronavirus infection from the nervous system. One of the vivid illustrations of the work of neurologists in our Republic of Belarus is a clinical case of patient O. being treated in October November 2020. The novelty in the work was added by the presence of ONMK against the background of the just transferred</span></p>
<p><span style="font-weight: 400;">coronavirus infection.</span></p>
<p><span style="font-weight: 400;">Clinical case</span></p>
<p><span style="font-weight: 400;">Medical history: patient O., born in 1969, was treated from 17 to 26.10.2020 in a specialized department of one of the hospitals in the city of Voronezh for patients with a new coronavirus infection (that is, in the center of category "B") with a diagnosis : Coronavirus infection caused by the COVID-19 virus. Community-acquired pneumonia of viral and bacterial etiology, mild course. DN 0 ", from 10/26/2020 to 11/12/2020, in the same institution, inpatient treatment was carried out for CMB, diagnosis: CMB, ischemic stroke in the basin of the left MCA from 10/26/2020, an unspecified pathogenetic variant with the formation zones of ischemia in the left and right hemispheres of the cerebellum and in the region of the basal nuclei on the left, with spastic tetraparesis with a predominance on the left, dysarthria syndrome, severe trunk ataxia, cognitive impairment. Cystic changes in the left hemisphere of the brain. Neurogenic bladder.</span></p>
<p><span style="font-weight: 400;">Dyscirculatory encephalopathy 2, decompensation stage, cephalgic</span></p>
<p><span style="font-weight: 400;">syndrome, vestibuloatactic disorders. Hypertension 3, risk</span></p>
<p><span style="font-weight: 400;">MTR 4. ABS. CHF stage 1 ".</span></p>
<p><span style="font-weight: 400;">Transferred to the department of ONMK BUZ VO "Kalacheevskaya RB" for early</span></p>
<p><span style="font-weight: 400;">rehabilitation on 12/11/2020, where he was until 16/11/2020 (short term</span></p>
<p><span style="font-weight: 400;">hospitalization was associated with aggravated problems with</span></p>
<p><span style="font-weight: 400;">urination), was admitted to our Republic of Belarus in the acute period of stroke (up to 21 days</span></p>
<p><span style="font-weight: 400;">from the moment of development).</span></p>
<p><span style="font-weight: 400;">The situation with the function of the patient's respiratory system was assessed</span></p>
<p><span style="font-weight: 400;">as stable, the diagnosis of the therapist and infectious disease specialist upon admission:</span></p>
<p><span style="font-weight: 400;">"Coronavirus infection caused by the COVID-19 virus, PCR at</span></p>
<p><span style="font-weight: 400;">a study carried out three times on October 29, October 31, and November 5, 2020, negative.</span></p>
<p><span style="font-weight: 400;">Community-acquired pneumonia of viral and bacterial etiology, mild course,</span></p>
<p><span style="font-weight: 400;">DN 0 ". According to CT of the lungs, there is a significant positive dynamics in</span></p>
<p><span style="font-weight: 400;">compared with the onset of the disease: 10/16/2020 - signs of bilateral</span></p>
<p><span style="font-weight: 400;">polysegmental pneumonia, CT 2 lesion volume, COVID-19 probability</span></p>
<p><span style="font-weight: 400;">high. Conclusion CT from 05.11.2020: signs of bilateral viral</span></p>
<p><span style="font-weight: 400;">pneumonia, CT 1 (positive dynamics). According to reports,</span></p>
<p><span style="font-weight: 400;">the patient's presence in the general department did not pose a threat to</span></p>
<p><span style="font-weight: 400;">others.</span></p>
<p><span style="font-weight: 400;">Complaints noted upon admission to the Kalacheyevskaya RB: head</span></p>
<p><span style="font-weight: 400;">pain, dizziness, poor memory, weakness in the limbs, more in the left,</span></p>
<p><span style="font-weight: 400;">inability to maintain the vertical position of the body, violation</span></p>
<p><span style="font-weight: 400;">speech, fear, urinary disorders.</span></p>
<p><span style="font-weight: 400;">Neurological status: clear consciousness, in place, time, own</span></p>
<p><span style="font-weight: 400;">the personality is oriented correctly; from the side of the cranial nerves - without</span></p>
<p><span style="font-weight: 400;">features; strength in the right limbs - 4 points, in the left limbs - 1</span></p>
<p><span style="font-weight: 400;">point, the tone in them is increased according to the spastic type, deep reflexes</span></p>
<p><span style="font-weight: 400;">lively on both sides; does not perform coordination tests, withholding</span></p>
<p><span style="font-weight: 400;">sitting position is impossible due to ataxia; positive pathological</span></p>
<p><span style="font-weight: 400;">foot marks on both sides, delay-type pelvic dysfunction</span></p>
<p><span style="font-weight: 400;">urine, urination through the catheter, no sensory disturbances were received,</span></p>
<p><span style="font-weight: 400;">there was severe dysarthria; emotionally extremely labile, extremely</span></p>
<p><span style="font-weight: 400;">worried about his health, expresses obsessive fears, fears;</span></p>
<p><span style="font-weight: 400;">dyssomnia, depressive mood are noted [3].</span></p>
<p><span style="font-weight: 400;">Present symptoms: motor, atactic, cerebellar,</span></p>
<p><span style="font-weight: 400;">cognitive, emotional-volitional disorders, post-stroke disorders</span></p>
<p><span style="font-weight: 400;">function of the bladder.</span></p>
<p><span style="font-weight: 400;">Upon admission, testing was carried out according to standard</span></p>
<p><span style="font-weight: 400;">methods: NIHSS - 19, Rehabilitation routing scale - 5, index</span></p>
<p><span style="font-weight: 400;">Rivermead mobility - 0.</span></p>
<p><span style="font-weight: 400;">Rehabilitation goals: to increase the degree of self-care, to reduce</span></p>
<p><span style="font-weight: 400;">the degree of focal neurological, emotional, cognitive impairment,</span></p>
<p><span style="font-weight: 400;">normalize the passage of urine [2, 4, 5].</span></p>
<p><span style="font-weight: 400;">Period of stroke at the time of admission to the Republic of Belarus (10 days from occurrence)</span></p>
<p><span style="font-weight: 400;">treated as acute (up to 21 days).</span></p>
<p><span style="font-weight: 400;">Data from the most important surveys:</span></p>
<p><span style="font-weight: 400;">X-ray CT of the brain from 10/12/2020: ischemic stroke in</span></p>
<p><span style="font-weight: 400;">the left hemisphere of the cerebellum. Forming cystic changes in the left</span></p>
<p><span style="font-weight: 400;">hemisphere of the brain.</span></p>
<p><span style="font-weight: 400;">Ultrasound of the bladder from 11/16/2020: Urinary retention.</span></p>
<p><span style="font-weight: 400;">Examination by a urologist from 11/16/2020: Neurogenic bladder.</span></p>
<p><span style="font-weight: 400;">Chronic urinary retention. Urethritis.</span></p>
<p><span style="font-weight: 400;">During the previous inpatient treatment in the department,</span></p>
<p><span style="font-weight: 400;">specializing in the admission of patients with a new coronavirus infection,</span></p>
<p><span style="font-weight: 400;">correction of bladder dysfunction was performed - conservative</span></p>
<p><span style="font-weight: 400;">therapy did not give the desired effect, but the patient refused in writing</span></p>
<p><span style="font-weight: 400;">the epicystostomy prescribed by the urologist. In the future, the situation with</span></p>
<p><span style="font-weight: 400;">urinary tract exacerbated, and on November 16, 2020, the patient was</span></p>
<p><span style="font-weight: 400;">hospitalized in the urology department, where an urgent</span></p>
<p><span style="font-weight: 400;">epicystostomy after obtaining the patient's consent to the operation. After</span></p>
<p><span style="font-weight: 400;">stabilizing the situation was again hospitalized in the department for treatment</span></p>
<p><span style="font-weight: 400;">ONMK 11/23/2020</span></p>
<p><span style="font-weight: 400;">Positive dynamics in neurological status during translation</span></p>
<p><span style="font-weight: 400;">is absent, on the part of the mental status, the emotional</span></p>
<p><span style="font-weight: 400;">lability, concern about one's well-being, dyssomnia, depressive</span></p>
<p><span style="font-weight: 400;">mood,periodically with mild visual hallucinations.</span></p>
<p><span style="font-weight: 400;">Surveys carried out: UZDS BCA from 11/25/2020: effect</span></p>
<p><span style="font-weight: 400;">stagnation (thickening) of blood in the IJV on the left, non-rectilinear course of the PA on the left in 2</span></p>
<p><span style="font-weight: 400;">segment due to vertebrogenic influence.</span></p>
<p><span style="font-weight: 400;">General urinalysis: partial sanitation achieved:</span></p>
<p><span style="font-weight: 400;">11/23/2020: density 1012, protein 0.31 g / l, leukocytes 23-25-38 in p.z.,</span></p>
<p><span style="font-weight: 400;">erythrocytes 456 in the PC, mucus +.</span></p>
<p><span style="font-weight: 400;">12/04/2020: density 1013, protein 0.1 g / l, leukocytes 19-17-15 in p.z.,</span></p>
<p><span style="font-weight: 400;">erythrocytes 123 per p.z., mucus 0.</span></p>
<p><span style="font-weight: 400;">Received the following treatment: neurocytoprotectors (Cereton 4 ml (1000</span></p>
<ol>
<li><span style="font-weight: 400;">mg) No. 10, Mexidol 5% 5 ml No. 10, Cytoflavin 10 ml intravenously drip),</span></li>
</ol>
<p><span style="font-weight: 400;">on the recommendation of a urologist - antibiotic therapy: amikacin 1 g 2 times a day</span></p>
<p><span style="font-weight: 400;">intravenously for 10 days. Due to the long immobile state for</span></p>
<p><span style="font-weight: 400;">prevention of secondary thromboembolic complications received</span></p>
<p><span style="font-weight: 400;">anticoagulants (heparin 20 thousand units per day subcutaneously for 14 days), treatment according to</span></p>
<p><span style="font-weight: 400;">recommendations of a cardiologist (antihypertensive therapy intravenously drip</span></p>
<p><span style="font-weight: 400;">magnesium sulfate 25% 10 ml No. 5, oral lisinopril 5 mg per day 13</span></p>
<p><span style="font-weight: 400;">days), lipid-lowering therapy (simvastatin 20 mg at night), sedation (in</span></p>
<p><span style="font-weight: 400;">the form of antidepressants and antipsychotics Elzepam 1 ml intramuscularly No. 5,</span></p>
<p><span style="font-weight: 400;">haloperidol 1 ml intramuscularly No. 5, amitriptyline 2.5% 2 ml No. 3</span></p>
<p><span style="font-weight: 400;">intramuscularly), regular bowel movements were controlled</span></p>
<p><span style="font-weight: 400;">non-drug methods [4-7]. Classes were held with specialists</span></p>
<p><span style="font-weight: 400;">multidisciplinary team [4]: physiotherapy (magnetotherapy along</span></p>
<p><span style="font-weight: 400;">spine No. 7), massage of the chest according to the gentle method No. 10; Exercise therapy:</span></p>
<p><span style="font-weight: 400;">breathing exercises, posture treatment, passive verticalization,</span></p>
<p><span style="font-weight: 400;">early activation; psychological counseling of the patient and members</span></p>
<p><span style="font-weight: 400;">families, rational psychotherapy, occupational therapy for the purpose of recovery</span></p>
<p><span style="font-weight: 400;">self-care skills, speech therapy counseling and treatment</span></p>
<p><span style="font-weight: 400;">dysarthria.</span></p>
<p><span style="font-weight: 400;">Final Clinical DS: "CVD: Recovery Period</span></p>
<p><span style="font-weight: 400;">CMC - ischemic stroke in the left MCA from 10/26/2020, unspecified</span></p>
<p><span style="font-weight: 400;">pathogenetic variant with the formation of ischemic zones in the left hemisphere</span></p>
<p><span style="font-weight: 400;">cerebellum and in the region of the thalamus on the left, with a syndrome of dysarthria, expressed</span></p>
<p><span style="font-weight: 400;">trunk ataxia, pronounced spastic tetraparesis with</span></p>
<p><span style="font-weight: 400;">predominance on the left, cognitive impairment, asthenosubdepressive</span></p>
<p><span style="font-weight: 400;">syndrome. Cystic changes in the left hemisphere of the brain.</span></p>
<p><span style="font-weight: 400;">Neurogenic bladder. Chronic urinary retention.</span></p>
<p><span style="font-weight: 400;">Urethritis. Epicystostomy from 17.11.2020, Dyscirculatory encephalopathy 2,</span></p>
<p><span style="font-weight: 400;">decompensation stage, cephalgic syndrome, vestibuloatactic</span></p>
<p><span style="font-weight: 400;">violations. Essential hypertension 3, risk of CVC 4. ABS. CHF 1 tbsp.</span></p>
<p><span style="font-weight: 400;">Coronavirus infection caused by COVID-19 virus (start of treatment for</span></p>
<p><span style="font-weight: 400;">10/17/2020). Community-acquired pneumonia of viral and bacterial etiology,</span></p>
<p><span style="font-weight: 400;">easy course, period of convalescence. DN 0 ".</span></p>
<p><span style="font-weight: 400;">Treatment results:</span></p>
<p><span style="font-weight: 400;">1) the passage of urine through the epicystostomy is normalized, sanitation has occurred</span></p>
<p><span style="font-weight: 400;">urine, visually light urine along the catheter, normalization is achieved and</span></p>
<p><span style="font-weight: 400;">general urine analysis, and biochemical blood test; persists</span></p>
<p><span style="font-weight: 400;">violation of pelvic functions by the type of urinary retention;</span></p>
<p><span style="font-weight: 400;">2) normalization of mental status in the form of disappearance of obsessive</span></p>
<p><span style="font-weight: 400;">fears and fears, better sleep, the emergence of cooperation with staff</span></p>
<p><span style="font-weight: 400;">medical and rehabilitation profile in achieving the set goals,</span></p>
<p><span style="font-weight: 400;">disappearance of negativism;</span></p>
<p><span style="font-weight: 400;">3) increasing the level of mobility, the degree of self-service against the background</span></p>
<p><span style="font-weight: 400;">improvement of indicators of neurological status and decrease in severity</span></p>
<p><span style="font-weight: 400;">paresis, ataxia, reduction of dysarthric manifestations; with certainty</span></p>
<p><span style="font-weight: 400;">sits in bed, takes food on his own, can shave himself, wash</span></p>
<p><span style="font-weight: 400;">head, partially treat the body with wet wipes, went into</span></p>
<p><span style="font-weight: 400;">upright position with a walker, began to take steps about</span></p>
<p><span style="font-weight: 400;">supports with outside control [5].</span></p>
<p><span style="font-weight: 400;">The goals of rehabilitation have been achieved and in quantitative terms in the form</span></p>
<p><span style="font-weight: 400;">decrease in standard NIHSS scores from 19 to 16 points, changes</span></p>
<p><span style="font-weight: 400;">points of the Scale of rehabilitation routing from 5 to 4, index</span></p>
<p><span style="font-weight: 400;">Rivermead mobility from 0 to 7 [4].</span></p>
<p><span style="font-weight: 400;">The prognosis for recovery and restoration of the functions of the nervous,</span></p>
<p><span style="font-weight: 400;">respiratory, cardiovascular system favorable, by function</span></p>
<p><span style="font-weight: 400;">urinary system, the prognosis is doubtful. Likely conservation</span></p>
<p><span style="font-weight: 400;">residual phenomena of paresis and ataxia with a further prospect of reaching</span></p>
<p><span style="font-weight: 400;">disability, but partial self-care.</span></p>
<p><span style="font-weight: 400;">Recommendations for secondary prevention of stroke are given,</span></p>
<p><span style="font-weight: 400;">corrected hypotensive (perindopril 10 mg 1-2 times a day,</span></p>
<p><span style="font-weight: 400;">indapamide 2.5 mg per day, amlodipine 5 mg once a day with high numbers</span></p>
<p><span style="font-weight: 400;">BP), hypolipidemic (atoris 20 mg at night under the control of</span></p>
<p><span style="font-weight: 400;">cholesterol, lipoproteins, atherogenic index after 2 months),</span></p>
<p><span style="font-weight: 400;">anticoagulant (warfarin 2.5 mg once a day after dinner under control</span></p>
<p><span style="font-weight: 400;">INR after 2 days) therapy [5]; maintenance therapy prescribed</span></p>
<p><span style="font-weight: 400;">neuroprotective agents (Mexidol 125 mg 3 times 1 month, Cereton 1 capsule 3 times a</span></p>
<p><span style="font-weight: 400;">day 1 month, cytoflavin 2 tablets 2 times 1 month), activities for</span></p>
<p><span style="font-weight: 400;">prevention of stress ulcers (proton pump inhibitor omeprazole 20 mg 2</span></p>
<p><span style="font-weight: 400;">once a day for 1 month), registration with a dispensary to a neurologist and urologist,</span></p>
<p><span style="font-weight: 400;">therapist, infectious disease specialist at the place of residence [4, 6, 7].</span></p>
<p><span style="font-weight: 400;">Sent to the 2nd stage of rehabilitation in the rehabilitation department for</span></p>
<p><span style="font-weight: 400;">of patients with stroke from 04.12.2020 The patient and relatives were informed about</span></p>
<p><span style="font-weight: 400;">terms of referral to the ITU in the presence of persistent neurological defects</span></p>
<p><span style="font-weight: 400;">at the end of the rehabilitation period [6, 7]. The result of the 2nd stage of rehabilitation:</span></p>
<p><span style="font-weight: 400;">recovered independent walking, controls the pelvic functions,</span></p>
<p><span style="font-weight: 400;">the epicystomy was closed.</span></p>
<p></p>
<p><span style="font-weight: 400;">Conclusion</span></p>
<p><span style="font-weight: 400;">This article discusses the case of a complicated course</span></p>
<p><span style="font-weight: 400;">a new coronavirus infection with the development of ischemic stroke,</span></p>
<p><span style="font-weight: 400;">the effectiveness of the successive management of the patient in</span></p>
<p><span style="font-weight: 400;">specialized centers for the treatment of COVID-19 and stroke, inpatient</span></p>
<p><span style="font-weight: 400;">rehabilitation taking into account individual characteristics in the form of problems</span></p>
<p><span style="font-weight: 400;">urological profile and long-term correction of hypercoagulation. For 3 months</span></p>
<p><span style="font-weight: 400;">treatment, a lasting result was achieved in the form of restoration of independent</span></p>
<p><span style="font-weight: 400;">walking and disappearance of pelvic disorders. As a consequence, instead of</span></p>
<p><span style="font-weight: 400;">the need for long-term outside care for a patient with rough</span></p>
<p><span style="font-weight: 400;">dysfunction, the prospect of moderate a neurological defect, that is, the patient will be identified in 3, and not in 1 group disability. Intensive multi-directional treatment and rehabilitation from the very beginning</span></p>
<p><span style="font-weight: 400;">onset of the disease are highly cost-effective and</span></p>
<p><span style="font-weight: 400;">social significance.</span></p>
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