Instructions: read the situation and give explained

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

A 39-year-old patient went to the clinic complaining of sore throat with

swallowing, perspiration, fever up to 37.5 ºС. Sick for 3 days.

Objectively: the mucous membrane of the palatine tonsils and anterior palatine arches

hyperemic. Palatine tonsils of the first degree of hypertrophy, covered with a whitish coating

colors that are easily removable; plaque is rubbed between spatulas. Pharynx posterior

moderately hyperemic.

In the blood test: white blood cells - 13.5 × 109

/ l, red blood cells - 3.9 × 1012 / l, hemoglobin - 121

g / l, stab - 8%, segmented - 62%, lymphocytes - 26%, monocytes - 2%,

eosinophils - 2%, ESR - 25 mm / hour.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. After 2 days, the patient complained of sore throat, more with

swallowing, more on the right, there was pain in the right ear, difficulty swallowing and

when opening the mouth, general malaise. Objectively: temperature 38.5 ºС. Vote

has a nasal tone, opening the mouth is difficult. In the throat is determined

hyperemia of the mucous membrane, infiltration of the paratonsillar region on the right,

asymmetry of the pharynx due to displacement of the right tonsils medially. The tongue is sharply marked

and shifted somewhat to the left. Submandibular lymph nodes on the right are condensed, enlarged

and painful. How can you evaluate a similar situation? Diagnose and

justify.

4. What diagnostic methods need to be carried out?

5. Diagnose in accordance with ICD-10

 

 

Situational task 2 [K000113]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

A 24-year-old man complains of fever up to 40 ° C,

accompanied by chills; inspiratory dyspnea with a slight physical

load pain in the region of the heart, not associated with physical activity, moderate

intensities, long lasting.

From the anamnesis it is known that he has been using heroin for 4 years (injections in

ulnar veins, groin area). 2 weeks before hospitalization noted an increase

temperature up to 40 ° С. As an antipyretic, the patient took non-steroidal

anti-inflammatory drugs. After 3 days, the temperature dropped to 37.2-37.4 ° C,

I feel slightly better. However, after 10 days, the fever resumed, in

therefore the patient was hospitalized.

On examination: the skin is pale, clean. Peripheral lymph nodes not

enlarged. BMI - 18 kg / m2

. Body temperature - 38.9 ° C. In the lungs, vesicular breathing,

held in all departments. NPV - 18 per minute. Heart sounds are clear, based

the xiphoid process - systolic murmur, amplifying at the height of the inspiration with a delay

breathing. Focus 2 tones on a. pulmonalis. HELL - 110/60 mm RT. Art., heart rate - 100 beats per

a minute. The abdomen is soft, painless on palpation. The liver protrudes 2 cm from under

edges of the costal arch, the edge of the liver is smooth. Swelling of the feet and legs. Symptom of striking

negative on both sides. Urination is not impaired.

In the analyzes: red blood cells - 3.3 × 1012 / l, hemoglobin - 126 g / l, white blood cells - 15.8 × 109

/ l

stab neutrophils - 15%, ESR - 42 mm / h, serum albumin - 29 g / l,

creatinine - 66 μmol / l, GFR - 92 ml / min / 1.73 m2

, CRP - 120 mg / l (normal - up to 5 mg / l). IN

general urine analysis: specific gravity - 1016, red blood cells - 0-1 in the field of view.

When blood is inoculated for sterility, S. aureus sensitive to

Oxacillin, Ceftriaxone.

Echocardiography data: the size of the chambers of the heart is not increased. Mitral valve: sash

compacted, the nature of the movement of the valves multidirectional. Tricuspid valve:

the valves are compacted, thickened, visualized with an average echo density structure on

the middle and front cusps of 1.86 and 1.11 × 0.89 cm; sash movement pattern

multidirectional, tricuspid regurgitation of the III – IV degree.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. Choose the tactics of patient management, non-drug and drug

therapy. Justify your choice.

5. What is your further therapeutic tactic? Justify your choice.

 

Situational task 3 [K000114]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient R., 59 years old, taxi driver, walked from the parking lot on Monday evening

home, when he noted the appearance of severe pain behind the sternum with irradiation to the lower

jaw and left upper limb. At home, on the advice of his wife, he tried to stop the pain

Nitroglycerin syndrome without a significant effect. Total duration

pain syndrome for more than 20 minutes, the patient called an ambulance.

From the anamnesis it is known that over the past 10 years the patient has been increasing

blood pressure, up to a maximum of 170 and 90 mm RT. Art. Smokes 20 cigarettes per day in

over the past 20 years. Within a month, the first appearance of sternal

pain after intense physical exertion and passing at rest. Not examined

I did not receive treatment. Heredity: mother - 76 years old, suffering from arterial

hypertension, suffered myocardial infarction, father - died at age 55 from myocardial infarction.

On examination: a state of moderate severity. The skin is pale. Height

- 168 cm, weight - 90 kg, BMI - 32 kg / m2

. Heart sounds are muffled, accent is heard

second tone on the aorta, the rhythm is correct. HELL - 160 and 90 mm RT. Art. Heart rate - 92 beats per

a minute. The vesicular breathing, there are no secondary respiratory sounds. NPV - 22 per minute.

The abdomen is soft, painless. The dimensions of hepatic dullness according to Kurlov are 11 × 9 × 8 cm.

There are no peripheral edemas.

In the analyzes: total cholesterol - 6.7 mmol / L, TG - 2.8 mmol / L, HDL-C - 0.62

mmol / l; fasting glucose - 5.2 mmol / l; creatinine - 124 μmol / l, GFR (according to the formula

CKD-EPI) = 54.5 ml / min / 1.73 m2

(according to the outpatient card, the reduction of GFR to 55 ml / min / 1.73

m

2

also registered 4 months ago), albuminuria - 40 mg / day.

An ECG recorded sinus rhythm with a heart rate of 92 per minute, segment elevation

ST up to 4 mm I, AVL, V1-5, ST segment depression up to 2 mm II, III, AVF.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. What is the choice of myocardial reperfusion strategy in this case?

4. What drugs do you recommend for oral administration?

antiplatelet therapy? Justify your choice.

5. The patient was delivered to the regional vascular center, an emergency PCI was performed,

revealed occlusion of the anterior interventricular branch (LAD) of the left coronary

arteries, without restoration of the distal bed. Permanent stenting performed

1 drug-eluting stent. On day 3 from the time of primary PCI

the patient developed an attack of pain behind the sternum, with radiation to the upper left

limb, seizure stopped with a single dose of Nitroglycerin. How do you rate

this episode, what are the further tactics of patient management?

 

Situational task  4 [K000115]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient A., 45 years old, engineer, complains of chills, increased

body temperature up to 39 ° С, dyspnea of ​​inspiratory character during usual physical

load, dry cough, pain with deep breathing and coughing on the right in the subscapular

areas, general weakness, fatigue, sweating at night.

He fell ill acutely three days ago after hypothermia, when he appeared

the above complaints. He took antipyretic drugs with a slight

effect. I went to the local GP at the clinic. Due to severity

condition and suspected pneumonia was sent to the inpatient ward of the hospital

place of residence. History: 15 years working as an engineer in mechanical engineering

the factory. I do not smoke. Previously, the doctor was not observed.

Objectively: the general condition is serious. The skin is wet.

Cyanosis of the lips. Height - 175 cm, weight - 72 kg. Waist circumference - 100. Peripheral edema

not. Peripheral lymph nodes are not enlarged. Temperature 39 ° C. Breast

the cell is normosthenic. With deep breathing, some lag in the breath of the right

half of the chest. NPV - 24 per minute. To the right along the scapular line is marked

blunting percussion sound. On auscultation on the right below the angle of the scapula

weakened vesicular breathing, voiced small bubbling rales are heard.

The heart rhythm is correct, the ratio of tones is normal, there is no noise. Heart rate - 110 beats per

a minute. HELL - 100/60 mm RT. Art. With superficial palpation, the abdomen is soft,

painless. Kurlov's liver - 9 × 8 × 7 cm, with palpation the lower edge is smooth,

painless. The chair is decorated, without impurities. Urination is free,

painless.

Complete blood count: red blood cells - 4.08 × 1012 / l, hemoglobin - 120 g / l, white blood cells -

13.2 × 109

/ l, young - 2%, sticks - 12%, segments - 56%, lymphocytes - 27%, monocytes - 3%,

ESR - 38 mm / h.

On a chest x-ray in a direct and lateral projection:

on the right, in the lower and middle lobe, blackout in the form of an infiltrate.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. What tactics and therapy is required for the patient upon admission? Justify your

a choice. What are the criteria for the adequacy of therapy.

5. After 72 hours against the background of treatment, signs of intoxication and fever persist

(temperature 37.9 ° C), NPV - 22 per minute, there is purulent sputum. Generally

blood test: white blood cells - 11 × 109

/ l, neutrophils - 82%, young forms - 7%. What is

Your further therapeutic tactics? Justify your choice.

 

Situational task  5 [K000116]