Instructions: read the situation and give explained

ANSWERS ON QUESTIONS

Main part

Patient Z. 21 years old, disabled since childhood (cerebral palsy, mental retardation),

was admitted to the hospital with complaints from the mother about fatigue, hair loss,

decreased appetite, pallor of the skin, a perversion of taste (eats earth), unstable stool.

Anamnesis of life: refused food if meat was included in its composition (from the words

grandmothers). Often ate the ground. I haven’t been observed by doctors during this time, I haven’t been sick,

preventive vaccinations are not made.

Upon admission to the hospital, the condition is regarded as serious. Sick sluggish

almost indifferent to the environment. The consciousness is clear, it reacts sluggishly to the inspection. Leather and

visible mucous membranes are very pale. In the corners of the mouth "jamming." In lungs, vesicular breathing.

Heart sounds are rhythmic, muffled, at the apex and over the region of large vessels

systolic noise of a soft timbre is heard. The abdomen is soft, painless during

all departments on palpation. The liver is +3 cm below the rib edge. The spleen is palpated

at the edge of the hypochondrium, soft-elastic consistency. The urine is light, stool 1-2 times a day.

Vision and hearing are not impaired. The sclera is bright. Meningeal, cerebral and focal

Symptoms are not observed.

Complete blood count: hemoglobin - 60 g / l, red blood cells - 2.6 × 1012 / l, reticulocytes -

0.4%, color indicator 0.63, white blood cells 7.2 × 109

/ l, stab neutrophils -

2%, segmented neutrophils - 70%, eosinophils - 4%, lymphocytes - 16%, monocytes

- 10%, ESR - 18 mm / h.

Biochemical blood test: total protein - 68 g / l, urea - 3.2 mmol / l,

total bilirubin - 20.0 μmol / l, serum iron - 4.1 μmol / l (normal 10.6-33.6

μmol / l), the iron binding capacity of serum is 103 μmol / l (normal 40.6-62.5),

free hemoglobin is not detected.

Fecal occult blood test (three times): negative.

Questions:

1. Express the alleged preliminary diagnosis.

2. Justify your diagnosis.

3. Make an additional examination plan.

4. Make a differential diagnosis.

5. Make a treatment plan.

 

Situational task 20 [K000159]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient Z. 43 years old complains of fatigue, weakness, headaches,

shortness of breath when walking, pain in the knee joints that occur when descending along

stairs, “starting” pain, morning stiffness for 20 minutes, restriction

range of motion.

Anamnesis of the disease: it has been sick for about 4 years, when the above

complaints, did not seek medical help, self-medicated, took

infusions of herbs, periodically (1-2 times a year) - massage of the joints and trunk. Start

gradual disease: moderate pain in the knee joints after

significant physical activity, in the evening hours and in the first half of the night, morning

stiffness for 10 minutes Against the background of a relatively stable course of the disease 2-3

times a year - worsening of health: increased pain in the knee joints and the appearance

their swelling.

Anamnesis of life. From adolescence and adolescence was observed

significant weight gain, which is associated with good nutrition and sedentary

way of life. He worked as an accountant, for the last 6 years - as deputy chief

accountants of the enterprise. Hereditary history: mother has diabetes,

father died at the age of 52 from myocardial infarction, had some kind of disease

joints. Does not smoke, does not abuse alcohol.

Objective status: satisfactory condition, good physique,

increased nutrition. Height - 180 cm, weight - 107 kg, waist circumference - 115 cm. Skin

the integument is clean, physiological in color. Peripheral lymph nodes not

enlarged. There are no peripheral edemas. Muscle tone is normal. Joints of ordinary

forms, movements are not limited, crepitus in the knee joints during movement.

Respiratory system: respiratory rate - 18 in 1 minute. Palpation of the chest

painless, vocal trembling moderately weakened over the entire surface of the lungs.

Percussion - pulmonary sound, auscultatory - vesicular breathing on both sides,

no wheezing. Cardiovascular system: the apical impulse is not palpable.

Percussion: the right border of relative cardiac dullness 1 cm out from

the right edge of the sternum, the upper is the lower edge of the III rib, the left is 2 cm outward from the left

midclavicular line. Apex moderately muffled heart sounds, II tone accent

over the aorta, heart rate - 84 beats per minute, the rhythm is correct. HELL - 165/95 mm RT. Art.

Digestive system: tongue and oral mucosa pink, clean. Stomach

increased in volume, symmetrical, involved in the act of breathing, soft. Palpation of organs

the abdominal cavity is complicated due to excess subcutaneous fat. Dimensions

according to Kurlov, 9 × 8 × 7 cm. The size of the spleen is 8 × 5 cm.

Laboratory and instrumental data.

General blood test: red blood cells - 4.9 × 1012 / l, hemoglobin - 147 g / l, white blood cells -

8.2 × 109

/ l, eosinophils - 2%, stab neutrophils - 1%, segmented

neutrophils - 67%, lymphocytes - 25%, monocytes - 4%.

Urinalysis: relative density - 1019, protein - 0.033 g / l, epithelium -

single in sight.

Methodological center for accreditation of specialists_SZ_Medical business_2018

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Biochemical blood test: total protein - 68 g / l, albumin - 55%, globulins

- 45%, total bilirubin - 18 μmol / l, direct - 13 μmol / l, indirect - 5 μmol / l,

glucose - 6.4 mmol / l, total cholesterol - 7.1 mmol / l, lipoprotein cholesterol

high density - 0.78 mmol / l, triglycerides - 2.6 mmol / l, fibrinogen content

- 5.3 g / l.

ECG: sinus rhythm, 80 per min. Horizontal floor. email axis. Hypertrophy of the left

ventricle.

Questions:

1. Express the alleged preliminary diagnosis.

2. Justify your diagnosis.

3. Make an additional examination plan.

4. Make a differential diagnosis.

5. Make a treatment plan.

 

Situational task 21 [K000160]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

A 46-year-old man, a driver, was admitted to the hospital ward

by yourself. Complaints of sharp pain of a constant nature in the epigastric region

with irradiation in the back, in the left half of the abdomen, nausea, vomiting once eaten

food that does not bring relief, moderate bloating, general weakness,

lack of appetite at the time of inspection.

The onset of the disease is associated with the fact that on the eve of the evening he noted with friends

holiday, there were errors in the diet - taking spicy and fatty foods, alcohol. Similar

the pains were about a year ago, also arose after errors in the diet, stopped

after receiving No-shpa. Often previously noted a feeling of heaviness and bloating in the abdomen after

taking fatty foods. Currently notes the severity and feeling of “bursting” in

belly, oily, greasy, fetid stool 3 times during the last

days. Diuresis is not broken. According to his wife - abuses alcohol for

last seven years.

Objectively: the condition is satisfactory, the consciousness is clear. Body type

normosthenic, low nutrition. The skin of the upper half of the body

hyperemic, clean. Tongue dry, yellowish overlaid. In the lungs breathing

harsh, no wheezing. NPV - 18 per minute. Heart sounds are muffled, rhythmic. Heart rate

- 92 beats per minute. HELL - 110/70 mm RT. Art. Liver palpation is dense,

painless, near the edge of the costal arch. The size according to Kurlov is 10 × 9 × 8 cm. The spleen is not

palpated. The abdomen is somewhat swollen, is involved in the act of breathing, is moderately painful

on palpation in the epigastric region. Symptoms of peritoneal irritation -

negative.

Laboratory data.

Complete blood count: white blood cells - 9.6 × 109

/ l, ESR - 16 mm / h.

Urinalysis: relative density - 1022, protein - 0.033%, fecal analysis

- steatorrhea, creatorrhea, amylorrhea.

Ultrasound OBP: the liver is enlarged, with periportal consolidations, gall bladder

75 × 35 mm, in the lumen a calculus of 8 mm in diameter, with an acoustic track.

The pancreas of a heterogeneous structure due to hypo- and hyperechoic foci,

few calcifications, uneven expansion of the main

pancreatic duct, head sizes increased to 5 cm. Free fluid in

there is no abdominal cavity.

The patient refused FGDS.

Questions:

1. Express the alleged preliminary diagnosis.

2. Justify your diagnosis.

3. Make an additional examination plan.

4. Make a differential diagnosis.

5. Make a treatment plan.

 

Situational task 22 [K000161]