Instructions: read the situation and give explained

ANSWERS ON QUESTIONS

Main part

A 28-year-old man consulted a local GP with complaints of

fever up to 39.2 ° С with chills, bleeding dѐsen, appearance

"Bruises" on the skin for no apparent reason, general weakness. Considers herself ill in

for 7 days, when there was an increase in temperature, he took Paracetamol with

short-term effect. The weakness began to grow progressively, appeared

bleeding.

From the anamnesis of life: the presence of chronic diseases denies. Parents

are healthy. Has a special secondary education, works as a technologist. He served in the army

on the submarine.

Objectively: a state of moderate severity. Body temperature 37.5 ° C.

The skin is pale, normal humidity. On the skin of the lower extremities - ecchymosis;

petechiae on the skin of the shoulders, forearms; in the oral cavity - single petechial

elements. With auscultation, vesicular breathing, NPV - 19 per minute. Heart sounds

muffled, the rhythm is correct. Heart rate - 92 beats per minute. HELL - 100/65 mm RT. Art. Stomach

palpation is soft, painless. The edge of the liver is palpated 1 cm below the edge

edge of the arch, Kurlov’s dimensions are 16 × 10 × 9 cm. The spleen is palpable, elastic,

painless, percussion dimensions 10 × 8 cm.

Complete blood count: erythrocytes - 2.3 × 1012 / L, HB - 78 g / L, platelets - 30 × 109

/ l

white blood cells - 28.9 × 109

/ l, blasts - 32%, myelocytes - 0%, young neutrophils - 0%,

stab neutrophils - 5%, segmented neutrophils - 38%, lymphocytes -

25%, ESR - 30.

Questions:

1. What preliminary diagnosis can be made?

2. Justify your diagnosis.

3. What examinations should be prescribed to clarify the diagnosis?

4. Select and justify the tactics of patient management.

5. What complications are possible with this disease?

Situational task 9 [K000120]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

At the doctor’s therapist’s appointment, a 61-year-old woman in a clinic

complains of the presence of painless tumor-like elastic formations

on the lateral surface of the neck and in the axillary areas, as well as on severity in the left

hypochondrium with fast walking, increased sweating. Above complaints

appeared about a year ago, gradually increased.

Objectively: the general condition is satisfactory. Skin and visible

mucous membranes of normal color. Conglomerates of enlarged submandibular palpated

cervical, axillary, inguinal lymph nodes, with palpation - elastic,

painless, inactive, skin above them is not changed, symmetrically enlarged -

cervical and submandibular up to 2-3 cm, axillary up to 3-4 cm, inguinal up to 4 cm in diameter.

In the lungs, vesicular breathing, wheezing is not heard, NPV - 18 per minute. Heart sounds

clear, heart rate - 78 beats per minute. HELL - 120/80 mm RT. Art. The abdomen is soft, painless.

The edge of the liver does not protrude from the edge of the costal arch. The spleen protrudes 2 cm from under

edges of the costal arch, the edge is elastic, painless.

Complete blood count: red blood cells - 3.6 × 1012 / l, HB - 129 g / l, platelets -

200 × 109

/ l, white blood cells - 39 × 109

/ l, stab neutrophils - 2%, segmented

neutrophils - 2%, lymphocytes - 92%, monocytes - 4%, ESR - 30 mm / h, Botkin-Gumprecht shadow - 1-2 in the field of view.

Questions:

1. What preliminary diagnosis can be made?

2. Justify your diagnosis.

3. What examinations should be prescribed to clarify the diagnosis?

4. Select and justify the tactics of patient management.

5. What is the prognosis for this disease, and what are the possible complications?

Accreditation Center

 

Situational task 10 [K000121]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient L. 48 years old works as a teacher, turned to the clinic with complaints

for pain in the metacarpophalangeal, proximal interphalangeal joints of the hands,

Wrist, shoulder, ankle joints, metatarsophalangeal joints of the feet;

weakness in the hands; morning stiffness before lunch; subfebrile temperature

in the evenings, general weakness.

From the anamnesis. Considers herself ill for about 3 months, when pain appeared in

joints. I did not seek medical help, was treated with non-steroidal

anti-inflammatory ointments, without improvement. Over the last month

there were pains and swelling in the joints of the hands, feet, in the wrist and ankle

joints, morning stiffness during the day, low-grade body temperature. Lost weight

for the period of the disease by 6 kg.

General condition is satisfactory. The skin is clean, cyanosis, edema

not. Peripheral lymph nodes are not enlarged. The vesicular breathing, no wheezing. NPV

- 18 per minute. Heart sounds are clear, the rhythm is correct. Heart rate - 78 beats per minute. HELL -

120/70 mmHg Art. The abdomen is soft, painless. Liver at the edge of the costal arch.

Local status: brushes are correct. II, III proximal interphalangeal

joints and II, III metacarpophalangeal joints painful, swollen. Soreness in

wrist joints, shoulder joints. The grip of the right hand is 80%, the left is 70%.

Assessment of health on a visual analogue scale (YOUR) - 60 mm.

Survey

Complete blood count: red blood cells - 3.5 × 1012 / l, hemoglobin - 131 g / l, white blood cells -

8.6 × 109

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

neutrophils - 55%, lymphocytes - 30%, monocytes - 6%, ESR - 54 mm / h.

Biochemical blood tests: glucose - 3.2 mmol / l, total bilirubin - 15

μmol / l, creatinine - 54 μmol / l; total protein - 76 g / l, albumin - 50%, globulins:

α1 - 6%, α2 - 14%, β - 12%, γ - 17%, CRP - 17.2 mg, fibrinogen - 5.8 g / l, uric acid -

0.24 mmol / L (norm 0.16-0.4 mmol / L).

Rheumatoid factor: ELISA - 62 IU / ml (normal up to 15 IU / ml). Antibodies to DNA -

negative. ATsP> 200 IU / ml.

On radiography of the hands and feet: the joint spaces are moderately narrowed at

proximal joints of the hands. Single erosion is determined. Bone structure

changed due to epiphyseal osteoporosis at the level of the metacarpophalangeal joints,

metatarsophalangeal joints, single cystic enlightenments.

Questions:

1. Assume the most likely diagnosis.

2. Justify your diagnosis.

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

Methodological center for accreditation of specialists_SZ_Medical business_2018

eleven

4. The drug of which group of drugs would you recommend to the patient in

composition of combination therapy? Justify your choice.

5. After 6 months of regular therapy: hemoglobin - 134 g / l, ESR - 38 mm / hour, CRP -

10.2 mg / l, RF - 17.2 IU / ml, serum iron - 19 μmol / l. Pains persist

in II, III metacarpophalangeal, proximal interphalangeal joints of the hands,

Wrist joints, morning stiffness up to 2-3 hours. What is your

further treatment tactics? Justify your choice.

 

Situational task 11 [K000122]