Instructions: read the situation and give explained

ANSWERS ON QUESTIONS

Main part

Patient M., 24 years old, turned to the local GP with complaints of

headache, general weakness and fatigue, decreased appetite.

From the anamnesis, it is known that at the age of 14 years after suffering an ARI in a patient

edema of the face appeared, subfebrile temperature persisted for 3-4 months,

there were changes in the urine. He was treated by a pediatrician for about a year "from jade",

received prednisone. Last year I felt good, there were no noticeable edema.

During the physical examination revealed an increase in blood pressure - 140/90 mm RT. Art. and pasty face.

It was recommended to contact the clinic at the place of residence for examination and

diagnosis verification.

On examination: normal physique, BMI = 21 kg / m2

skin is pale, dry,

there are traces of calculations on the hands, lower back, torso, swelling of the face and hands. Tongue

dry, with a brownish coating. In the lungs, vesicular breathing, no wheezing. Borders

relative cardiac dullness expanded to the left by 1.5 cm from the mid-clavicular

lines. Pulse - 76 beats per minute, high. HELL - 140/90 mm RT. Art. The stomach is soft

painless on palpation in all departments. The liver and spleen are not enlarged.

The symptom of lumbar effusion is negative. Marks a decrease

urine output. There are no edemas on the lower extremities.

General blood test: red blood cells - 3.2 × 1012 / l, hemoglobin - 105 g / l, white blood cells -

5.2 × 109

/ l, stab neutrophils - 4%, segmented neutrophils - 65%,

eosinophils - 3%, monocytes - 5%, lymphocytes - 23%, ESR - 12 mm / h.

Biochemical blood tests: total cholesterol - 7 mmol / l, creatinine

blood - 170 μmol / l, blood urea - 11 mmol / l.

In urine tests: specific gravity - 1009, protein - 1.1%, white blood cells - 2-4 in the field

of vision, alkaline red blood cells - 7-10 in the field of view, hyaline cylinders - 2-3 in the field

view. Albuminuria - 250 mg / day. GFR (according to the formula CKD-EPI) - 55 ml / min.

The questions are:

1. Assume the most likely diagnosis.

2. Justify the alleged diagnosis.

3. Are additional studies needed to clarify the diagnosis?

4. What are the further tactics of patient management?

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

as a nephroprotective therapy? Justify your choice.

Situational task 31 [K000187]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

A 18-year-old patient consulted a local GP with complaints of pain in

abdomen, vomiting, fever.

Anamnesis: fell ill yesterday (according to the patient, after severe hypothermia), when

he developed pains in the joints of his hands and feet, the temperature rose to 38.5 ° C. In the morning

frequent vomiting, cramping abdominal pain, bloating.

Objectively: the patient has a temperature increase of up to 38 ° C, coated

dry tongue. Pathologies from the lungs and heart were not detected. Bloating is noted

abdomen and tension of the anterior abdominal wall, a positive symptom of ShchetkinBlyumberg. Pulse - 110 rpm. HELL - 110/70 mm RT. Art. Abundant petechial on legs

rashes. Severe swelling and tenderness on palpation of the ankles,

knee and wrist joints on the right and left.

Complete blood count: red blood cells - 4.2 × 1012 / l, hemoglobin - 136 g / l, platelets

- 200 × 109

/ l, white blood cells - 21.0 × 109

/ l, eosinophils - 12%, stab - 10%,

segmented - 68%, lymphocytes - 6%, monocytes - 4%, ESR - 42 mm / hour.

Biochemical blood tests: creatinine - 290 μmol / l, AcAT - 17 U / l;

AlAT - 23 U / L, glucose - 4.9 mmol / L.

General analysis of urine: specific gravity - 1021; protein - 0.068 g / l; white blood cells - 6-8 in the field

vision; erythrocytes - 20-25 in the field of view are fresh, unchanged.

The questions are:

1. Indicate the underlying syndrome in the clinical presentation.

2. Formulate a presumptive diagnosis.

3. With what diseases is it necessary to conduct differential diagnosis in

first of all?

4. What additional studies are needed to confirm the diagnosis?

5. What are the groups of drugs and non-drug treatments

are the most important in the treatment of this disease?

Situational task 32 [K000188]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient K., 39 years old, consulted a local GP with complaints of dry

cough, fever up to 37.5 ° C, general weakness, chest pain with

breathing. A history of hypothermia. Objectively: pallor of the skin,

slight lag of the right half of the chest during breathing. With percussion

Lungs A clear, lightweight sound over the entire surface of the lungs. On auscultation:

weakened breathing and pleural friction noise on the right side below the angle of the scapula.

X-ray examination of the chest organs - without pathology.

The questions are:

1. Formulate a preliminary diagnosis.

2. Justify your diagnosis.

3. Indicate the amount of additional examination necessary to clarify the diagnosis.

4. What diseases are required to conduct differential diagnosis?

this state?

5. With the progression of the disease, cough and chest pain decreased,

severe dyspnea appeared, dullness on clinical examination

percussion tone, weakening of vesicular respiration and vocal trembling in

lower parts of the right lung. What instrumental research should

run again and for what purpose?

 

 

Situational task 33 [K000190]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient K., 48 years old, an economist, consulted a general practitioner with

complaints of compressive pain behind the sternum and in the region of the heart, radiating to the left

shoulder arising when walking after 100 meters, sometimes at rest, stopping

with 1-2 tablets of Nitroglycerin in 2-3 minutes, shortness of breath, palpitations with

insignificant physical activity. Pain in the heart first appeared about 5 years

back. Accepts Nitroglycerin for pain relief, Cardicet 20 mg 2 times a day -

for the prevention of heart pain, Aspirin 100 mg at night. I took statins for about two

years, the last two years does not accept. Tolerance has decreased over the past six months.

physical activity. The patient smokes for about 20 years, 1 pack per day. Heredity:

father died at the age of 62 from myocardial infarction.

General condition is satisfactory. Normostenic Constitution.

There are no peripheral edemas. NPV - 18 per minute, in lungs vesicular breathing, wheezing

not. Borders of the heart during percussion: right - the right edge of the sternum IV intercostal space,

upper - III intercostal space, left - 1.0 cm inward from the left midclavicular line V

intercostal space. Heart sounds are muffled, the rhythm is correct, the emphasis is II tone above the aorta. Heart rate

- 82 beats per minute. HELL - 135/80 mm RT. Art. The liver and spleen are not palpable. Symptom

lumbar efflux negative.

Blood lipids: total cholesterol - 6.8 mmol / l; triglycerides - 1.7 mmol / l;

high density lipoprotein cholesterol - 0.9 mmol / L.

ECG at rest: rhythm - sinus, heart rate - 80 beats per minute. EOS is not rejected.

Single ventricular extrasystole.

Echo-KG: aortic wall compaction. Left ventricular posterior wall thickness

(TZSLZH) - 1.0 cm; the thickness of the interventricular septum (TMZHP) - 1.0 cm. Cameras

hearts are not dilated. Left ventricular ejection fraction (EF) - 57%. Violations

local and global contractility of the left ventricle was not detected.

VEM test: during the first stage of the load, compressive pain appeared

behind the sternum, accompanied by the appearance of depression of the ST segment up to 3 mm in I, II, V2-V6,

disappeared in the recovery period.

Coronary angiography: stenosis in / 3 of the left coronary artery - 80%, c / 3 envelope

arteries - 80%.

The questions are:

1. Formulate a clinical diagnosis.

2. Conduct a rationale for the clinical diagnosis.

3. What are the main risk factors for atherosclerosis.

4. Prescribe non-drug and drug treatment.

5. Are there indications for surgical treatment in this case?

 

Situational task 34 [K000191]