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ANSWERS ON QUESTIONS

Main part

Patient R., 38 years old, by profession a maintenance worker, turned to the clinic to

the general practitioner physician with complaints of fever up to 38.0 ºС, cough with

profuse mucopurulent sputum, non-intense pain in the chest when coughing,

headache, weakness in limbs, sweating. Ill acutely after

hypothermia.

Bad habits: smokes for more than 15 years at 20 cigarettes per day; related

there are no diseases. In the past few years, he has not left Moscow.

Objective data: the skin is pale, moist. Draws

attention increased sweating of the patient. The tonsils are covered in whitish

bloated, hyperemic. In lungs, breathing weakened on the right, multiple

wet small bubbling rales are heard at the corner of the right scapula. BH at rest until

26 per minute. Heart sounds are muffled, rhythmic, isolated extrasystoles. Heart rate - 100

beats per minute, blood pressure - 110/70 mm RT. Art. The abdomen is soft, painless. According to others

organs and systems without visible pathological abnormalities.

Laboratory and instrumental examination methods.

Clinical blood test: hemoglobin - 135 g / l, red blood cells 4.7 × 10 12 / l,

white blood cells 11 × 10 9 / l, stab - 28%, segmented - 57%; ESR - 35 mm / hour.

Urinalysis: relative density - 1018, protein - 0.99 g / l, hyaline

cylinders.

Biochemical blood test: ALT - 58 units / l; AST - 100 u / l; creatinine - 115

μmol / l; fibrinogen - 8 g / l.

ECG: sinus rhythm, correct, heart rate - 100 beats / min, single

supraventricular extrasystoles. Focal myocardial changes, myocardial hypertrophy

not.

Chest x-ray: focal basal infiltration

departments of the right lung, deformation of the root of the right lung.

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 groups of antibiotics are recommended to the patient for starting

antibiotic therapy? Stratify the severity of the disease and

risk factors.

5. After 3 days of therapy, body temperature returned to normal - 36.8 ° C, decreased

intoxication (decreased weakness, sweating, improved appetite), decreased

dyspnea. What is your further therapeutic tactic? Justify your choice.

 

Situational task 122 [K000460]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient R., 65 years old, a pensioner, when contacting a general practitioner

complains of fever up to 38 ° C, slight sputum

mucous character, headache, shortness of breath, palpitations and weakness in the limbs.

He became ill acutely after hypothermia. The patient suffers from ischemic heart disease, chronic cardiac

insufficiency; takes continuous therapy (Perindopril 2.5 mg 2 times,

Hydrochlorothiazide 12.5 mg, Veroshpiron 50 mg, Simvastatin 20 mg). Patient contacts

there was no tuberculosis and infectious diseases. In the last few years from

Moscow did not leave.

Objectively upon examination: the skin is pale, moist, cyanosis of the lips.

Body temperature 37.8 ° C. The tongue is covered with a whitish coating. In the lungs breathing

attenuated vesicular, multiple wet fine bubble rales

are heard in the lower part of the left lung. BH at rest up to 24 per minute. Heart sounds

muffled, rhythmic, isolated extrasystoles. Heart rate - 90 beats per minute, blood pressure -

110/70 mmHg Art. The liver 1 cm protrudes from under the edge of the costal arch. Dysuric

there are no phenomena. The legs are pasty. For other organs and systems without visible

pathological abnormalities.

Clinical blood test: hemoglobin - 126 g / l; erythrocytes - 4.2 × 10 12 / l;

white blood cells - 10.9 × 10 9 / l; stab - 10%, segmented - 77%; ESR - 30

mm / hour

Urinalysis: relative density - 1012, protein - 0.33 g / l, in sediment

white blood cells - 2–4 in the field of view.

Biochemical blood test: ALT - 38 units / l; AST - 35 units / l; urea - 9 mmol / l,

creatinine - 120 μmol / l.

ECG: sinus rhythm, correct, heart rate - 100 beats / min, single

supraventricular extrasystoles. Signs of left ventricular hypertrophy. Focal

no myocardial changes.

Chest x-ray: enhancement of pulmonary pattern in basal

departments of the left lung.

ECHO-KG: moderately expanded cavity of the left ventricle, posterior hypertrophy

walls of the left ventricle, ejection fraction - 45%.

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 groups of antibiotics are recommended to the patient for starting

antibiotic therapy? Stratify the severity of the disease and

risk factors. Justify your choice.

5. After 3 days of therapy, the temperature returned to normal - 36.6 ° C, feeling good

improved (no shortness of breath). What is your further therapeutic tactic? Justify

Your choice.

 

Situational task 123 [K000461]