Instructions: read the situation and give explained

ANSWERS ON QUESTIONS

Main part

Patient K., 58 years old, complains of increased expiratory dyspnea

character with slight physical exertion (washing, dressing),

accompanied by a whistle in the chest; paroxysmal cough with

an increase in sputum up to 20 ml per day in the morning, an increase in temperature to 37.8

° C.

Medical history: dry cough for the past 20 years. Last 10 years

began to notice expiratory shortness of breath with accelerated walking, ascent to the 2nd floor. IN

over the past year, shortness of breath sharply intensified and began to bother with normal

load, conversation, there was a thick, sparse sputum yellow-green. Exacerbations

2 times over the past year. 2 weeks worse: temperature rises to 37.8

° C, cough intensified, purulent sputum appeared, its volume increased, intensified

expiratory dyspnea. He took at home Ampicillin 250 mg 3 times a day, Berodual

2 breaths 4 times a day without improvement. He turned to the emergency room of the city hospital.

Anamnesis of life: smokes 30 years, 1.5 packs per day, consumes 1 time per month 200

ml of vodka. Works as a foreman at a construction site. Relatives of respiratory diseases

not. Allergic history is not burdened.

Objectively: the skin is moist, diffuse cyanosis. Temperature 37.5 ° C.

Height - 172 cm, weight - 60 kg. The chest is enlarged in anteroposterior size,

the smoothness of the supra- and subclavian fossae, the epigastric angle is obtuse. Percussion sound

- boxed. Mobility of the lower pulmonary margin along the mid axillary line -

2.5 cm. On auscultation - weakened vesicular breathing, scattered dry

wheezing on both sides. NPV - 24 per minute. Heart sounds are muffled, rhythm

correct. Heart rate - 100 beats per minute. HELL - 120/72 mm RT. Art. The stomach is soft

painless. The size of the liver according to Kurlov is 10 × 9 × 8 cm. There are no edemas.

Based on a modified British Medical Research Questionnaire

advice for assessing the severity of the state of mRSquestoinnaire - 4 points.

Complete blood count: erythrocytes - 4.42 × 1012 / l, HB -165 g / l, Нt - 50%, white blood cells -

8.4 × 109

/ l, eosinophils - 2%, stab neutrophils - 8%, segmented

neutrophils - 62%, lymphocytes - 25%, monocytes - 4%, ESR - 28 mm / hour.

General analysis of sputum - viscous, green. White blood cells - 100 in sight,

erythrocytes - no.

According to pulse oximetry, oxygen saturation is 88%.

FVD-FEV1 - 29%, VC - 52%, FEV1 / FVC index - 57%. When testing with

Salbutamol 4 doses Δ FEV1 - 2.12%.

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.

5. The patient's condition improved after 20 days: shortness of breath decreased. What is

Your further therapeutic tactics? Justify your choice.

 

Situational task  6 [K000117]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient T., 42 years old, was hospitalized in the hospital as directed by a general practitioner

local with complaints of weakness, drowsiness in the daytime, jaundice of the skin

integument, a feeling of heaviness in the right hypochondrium, periodic nosebleeds

after physical work, an increase in the abdomen in volume, edema on the lower extremities in

areas of feet and legs.

In the anamnesis: the severity in the right hypochondrium worries for the last 3

months. Over the past month, noted an increase in general weakness, an increase in the abdomen and

jaundice. Consumes 200 g of vodka daily for the past year, observed

at the narcologist. Drug use denied. Blood transfusions, operational

there were no interventions.

Objectively: a state of moderate severity. Consciousness is clear. Number Binding Test -

40 sec Height - 178 cm, weight - 62 kg. Skin of normal moisture, icteric. In the chest

and spider veins are visible on the upper back. The sclera of the eyes is icteric. Fathers

feet and lower third of the legs. In lungs, vesicular breathing, secondary respiratory

no noise. NPV - 18 per minute. With auscultation, heart sounds are rhythmic, no noise.

Heart rate - 78 beats per minute. HELL - 110/70 mm RT. Art. Tongue wet, raspberry, papillae

smoothed out. The abdomen is enlarged, the navel is flattened, on the anterior abdominal wall

expanded, convoluted veins are defined radially from the navel. In lying position, stomach

spread out. On palpation, soft, painful in the right hypochondrium. Liver size

according to Kurlov - 15 × 15 × 13 cm. The lower edge of the liver during palpation is dense, tuberous. Chair

decorated, brown, without pathological impurities. The size of the spleen is 15 × 12.

Urination is free, painless, urine is dark yellow.

General blood test: red blood cells - 4.1 × 1012 / l; Hb - 122 g / l; color indicator -

0.9%; platelets - 98 × 109

/ l, white blood cells - 3.2 × 109

/ l, eosinophils - 1%, stab

neutrophils - 4%, segmented neutrophils - 63%, lymphocytes - 29%, monocytes -

3%, ESR - 22 mm / h.

Biochemical analyzes: total bilirubin - 130 μmol / l, direct bilirubin -

100 μmol / L, ALT - 120 U / L, AST - 164 U / L. INR - 2, albumin - 28 g / l.

Fibrogastroduodenoscopy: varicose veins of the esophagus I tbsp.

Ultrasound examination of the abdominal cavity: anteroposterior size of the right

lobes of the liver - 170 mm, the contours are clear and uneven. Parenchyma of unevenly diffuse increased echogenicity. The diameter of the portal vein is 16 mm. Gall bladder

normal sizes, contents - bile. Hepatic choledoch is not expanded. Spleen

usually located, the structure is homogeneous, parenchyma of medium echogenicity. Square

spleens - 36.1 cm2

. Free fluid in the abdominal cavity.

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.

5. What are the possible complications of this disease?

Situational task 7 [K000118]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient U. 24 years old, medical assistant, was sent to a hospital with complaints of pain

inflammatory rhythm in the joints of the hands, ankles, the presence of morning

stiffness in joints up to 1 hour. Also notes an increase in body temperature to

low-grade figures in the evenings, the appearance of a rash on the face in the cheekbones, general

weakness, hair loss.

From the anamnesis: considers herself a patient for 2 years, when she began to celebrate

the appearance of hyperemia of the skin of the face and neck in response to insolation. Since the summer of this year

after hyperinsolation (resting in the south) and overheating, erythematous

rashes on the neck, arms. Two weeks after returning home noted

an increase in body temperature to febrile numbers. At the place of residence

the diagnosis of acute respiratory infections, antibiotic therapy was carried out without effect. At

an additional examination revealed protein in the urine. Sent to a hospital.

On examination: general condition of moderate severity. Skin integument:

erythematous rash in the form of a “butterfly” on the skin of the face, décolleté. Symmetric

edema to the lower third of the legs. Mucous clean. The vesicular breathing, no wheezing.

NPV - 17 per minute. Heart sounds are clear, the rhythm is correct. Heart rate - 92 beats per 1 minute,

HELL - 140/80 mm RT. Art. The abdomen is soft, painless, the liver does not protrude from the edge

costal arch along the mid-clavicular line. Urination is free,

painless. The chair is regular, decorated.

Swelling in the II, III metacarpophalangeal and II proximal

interphalangeal joints in the ankle joints; restriction of movements for

pain count, grip of hands - 80%; no deformation.

Survey

Complete blood count: red blood cells - 3.6 × 1012 / l, hemoglobin - 86 g / l, platelets -

100 × 109

/ l, white blood cells - 1.6 × 109

/ l, eosinophils - 1%, stab neutrophils - 8%,

segmented neutrophils - 59%, lymphocytes - 25%, monocytes - 4%, ESR - 22 mm / h.

The general analysis of urine is cloudy, the color is yellow, the density is 1.022, the reaction is acidic,

protein - 0.560 g / l, glucose - negative, white blood cells - 20-25 in the field of view.

Biochemical analysis of blood: creatinine - 118 μmol / l, urea - 8.8 mmol / l,

total protein - 67 g / l, albumin - 45%, α1 - 4%, α2 - 15%, β - 9%, γ - 27%, fibrinogen -

6.3 g / l Antibodies to DNA and antinuclear factor - more than 200 Units / ml.

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. Which groups of drugs would you recommend to the patient in

composition of combination therapy? Justify your choice.

5. After 6 months of regular therapy and compliance with the recommendations: red blood cells -

4.4 × 1012 / l, hemoglobin - 119 g / l, platelets - 210 × 109

/ l, white blood cells - 5.1 × 109

/ l

fasting glucose - 4.9 mmol / l, total cholesterol - 4.9 mmol / l, creatinine - 108

μmol / l, GFR (according to the formula CKD-EPI) = 60.3 ml / min; daily protein loss - 0.240

g / day What is your further therapeutic tactic? Justify your choice.

 

Situational task 8 [K000119]