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ANSWERS ON QUESTIONS
Main part
A 69-year-old patient was referred by a local GP to the clinic complaining of
severe shortness of breath with slight physical exertion, asthma attacks
at night. Deterioration is observed about a week before hospitalization.
From the anamnesis: 6 years ago, dilated cardiomyopathy was diagnosed.
The patient constantly received the selected treatment: Hypothiazide - 12.5 mg per day,
Fosinopril - 20 mg daily, Carvedilol - 12.5 mg 2 times a day. Weakness observed
during physical activity. The patient reported that a few days ago after
hypothermia appeared cough, body temperature increased to 37.4 ° C. Due to
growing weakness, stopped taking Carvedilol, used heavy drinkѐ,
vitamins. The condition has worsened.
Objectively: weight - 76 kg, height - 168 cm. Cyanosis. On auscultation: congestive rales
in the lungs on both sides; heart sounds are deaf, rhythmic, protodiastolic rhythm
gallop. Heart rate - 105 beats per minute. HELL - 105/70 mm RT. Art. Symmetric edema of the lower
limbs.
In blood tests: sodium - 138 mmol / l, potassium - 3.9 mmol / l.
ECG: sinus rhythm, blockade of the left bundle branch block, ventricular
extrasystoles. QRS 0.13 sec
Echocardiography: diffuse hypokinesia of the walls of the left ventricle, ejection fraction - 36%,
the final diastolic size of the left ventricle is 69 mm.
Questions:
1. Assume the most likely diagnosis.
2. What determines the severity of the patient's condition? What contributed to the development
heart failure decompensation? Justify your diagnosis.
3. Make and justify a plan for an additional examination of the patient.
4. What groups of drugs should be prescribed to the patient? How to be with the appointed
ACE inhibitor fosinopril in connection with blood pressure 105/70 mm RT. Art. - cancel
decrease or increase the dose? What to do with carvedilol?
5. If, despite adequate therapy, it is not possible to achieve persistent
heart failure compensation, are there any reserves in the treatment?
Situational task 53 [K000229]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Male F. 34 years old, a loader, during hospitalization in the pulmonology department
complains of weakness, weight loss in the last month, shortness of breath, pain in
chest
Objectively: the patient’s condition is moderate, temperature is 37.6 ° С,
smoothing of intercostal spaces is noted on the right, there is sharply reduced
voice trembling and significantly reduced percussion sound from the 5th rib along the shoulder blade
and axillary lines. The breathing in the upper parts of the right lung is somewhat
weakened, in the lower - not carried out. Left on all pulmonary fields - vesicular.
The rhythmic pulse, 82 beats per minute, satisfactory filling and tension,
tones are clear, no noise.
Laboratory data.
General blood test: white blood cells - 9.9 × 10 9 / l; eosinophils - 1%; stab
neutrophils - 3%; segmented neutrophils - 76%; lymphocytes - 15%; monocytes -
5%; ESR - 35 mm / hour.
General analysis of bronchial washings: leukocytes - 2-3 in the field of view, single
alveolar and epithelial cells.
Bronchial lavage water (3 analyzes) for Mycobacterium tuberculosis using
microscopy - KUM neg.
Inoculation of bronchial washings on non-specific microflora - growth
There is no pathogenic microflora.
Urinalysis: normal.
On the chest x-ray: on the right below the V rib to
aperture is determined by intense homogeneous dimming with a distinct oblique upper
the border.
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. Define the circle of diseases for differential diagnosis.
5. Define patient management tactics.
Situational task 54 [K000230]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient M., 35 years old, at the reception by a local GP
weakness, fatigue, cough with a small amount of sputum,
shortness of breath with little exertion, sweating at night for 1.5-2
months. Today, during a coughing fit, the patient felt a sharp pain in his right
half of the chest, increased shortness of breath, increased heart rate.
From the anamnesis: 3 years ago, a right-sided dry pleurisy was transferred, was treated by a doctor
general practitioner. Contact with tuberculosis patients denies. FLG passes
regularly, the last one year ago (without pathology).
Objectively: a state of moderate severity. Temperature - 37.5 ° C. Sick
low nutrition, the skin is pale, peripheral lymph nodes are not
enlarged. The right half of the chest lags in the act of breathing. NPV - 24 per minute.
Percussion on the right - tympanic sound, on the left - shortening in the upper sections
pulmonary sound. Auscultatory on the right - breathing is sharply weakened, on the left in
of the interscapular region, single wet rales are heard. Heart sounds are clear
the rhythm is correct, tachycardia. Pulse - 120 beats per minute, blood pressure - 90/50.
Laboratory data.
General blood test: red blood cells - 4.1 × 10 12 / l, hemoglobin - 143 g / l; white blood cells -
9.6 × 10 9 / l, eosinophils - 2%, stab neutrophils - 5%, segmented
neutrophils - 69%, lymphocytes - 19%, monocytes - 5%; ESR - 25 mm / hour.
Urinalysis: no pathological changes.
Analysis of sputum at the office: m / scopia - no CMC found.
Chest x-ray of the chest in a direct projection: on the right
easy collapsed by 1/5 of hemitrax due to the air layer. In the lung tissue in
upper and middle fields, focal shadows of different sizes, small and medium are determined
intensities prone to fusion. In C1, C2 on both sides - decay cavity 1-2.5 cm
in diameter. The roots are poorly differentiated. Heart without features.
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. Define the circle of diseases for differential diagnosis.
5. Define patient management tactics.
Situational task 55 [K000231]
Дата: 2019-12-10, просмотров: 261.