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ANSWERS ON QUESTIONS
Main part
Patient D., 50 years old, went to the clinic with complaints of frequent headaches,
intermittent thirst, dry mouth, frequent urination during the day and up to 6 times
the last few days, heaviness in the lumbar region, especially the last few
days after hypothermia and increased fatigue for about a week. Once
the temperature rose to 37.8 ° C. From the anamnesis - type 2 diabetes 3 years, receives
Metformin 2000 mg / s, blood glucose greater than 6 mmol / l on an empty stomach does not increase.
Hypertension about 5 years. Takes Valsartan 40-80 mg / day, depending
from the level of blood pressure. The maximum increase in blood pressure to 150/90 mm RT. Art. at working 135/80 mm
Hg. Art. Leads a sedentary lifestyle, works as a shift manager. Head
pain often occurs after a night shift. The mother has hypertension, the father
THEM. Smokes 5-6 cigarettes for 10 years.
On examination - increased nutrition. BMI - 29 kg / m 2 , waist (OT) - 100 cm.
The skin and mucous membranes of normal color. Percussion over the lungs is a lung sound.
Auscultatory vesicular breathing, no wheezing, NPV - 17 per minute. In the heart of tones
weakened, correct rhythm, II tone accent over the aorta, heart rate - 78 beats per minute. HELL -
135/85 mmHg Art. (S = D) The tongue is moist, clean, the abdomen is palpation painless,
slightly increased in volume due to subcutaneous fat. Liver sizes are not
enlarged. The spleen is not enlarged. Pasternatsky’s symptom is positive on both
parties. Peripheral pulsation in the arteries of the feet is preserved, not reduced.
In the general analysis of blood: red blood cells - 4.4 × 10 12 / l, hemoglobin - 142 g / l, color
indicator - 0.85, white blood cells - 11 × 10 9 / l, stab - 8%, segmented - 72%,
lymphocytes - 16%, monocytes - 4%. ESR - 25 mm / h.
In the general analysis of urine: specific gravity - 1018, protein - traces, white blood cells - 20-30 in
field of view, red blood cells 1-2 in the field of view.
In the biochemical analysis of blood: blood glucose - 5.2 mmol / L, HBA1c - 5.6%, ALT
- 25 IU / L, AST - 15 IU / L, creatinine - 75 μmol / L.
Radiography of the lungs - without pathology.
ECG - sinus rhythm, signs of left ventricular hypertrophy, heart rate - 84 beats per
a minute.
Ultrasound of the abdominal cavity - the liver is not enlarged, echogenicity is not changed, gall
the bubble is not enlarged, the wall is 2 mm, there are no calculi, the pancreas is uneven
compacted, not enlarged. The kidneys are not enlarged, deformity of the CLS on both sides, brushes
there are no calculi.
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. Prescribe therapy. Justify your choice.
5. 10 days after treatment, the general urine analysis returned to normal - there is no protein,
white blood cells - 1-2 in the field of view, normal blood count normalized - white blood cells
5 × 10 9 / l, ESR - 10 mm / h. Continued to remain normal target blood pressure - 130/80
and glycemia - 5.5 mmol / L. What is your further therapeutic tactic? Justify
Your choice.
Situational task 129 [K000936]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient D., 52 years old, came to the clinic with complaints of thirst, dry mouth,
frequent urination, up to 3 times at night, frequent occipital pain, fatigue with
physical activity. These complaints are disturbing throughout the year. From the anamnesis it was found out
that is overweight for many years, leads a sedentary lifestyle, works
accountant. Headaches occur after stress at work. Dry mouth
occurs after eaten sweet food, which the patient abuses. Earlier
the patient did not contact the doctors. The mother has hypertension. I do not smoke.
An allergic history is not a burden.
On examination of increased nutrition. BMI - 31 kg / m 2 , waist (OT) - 100 cm.
The skin and mucous membranes of normal color. Peripheral lymph nodes are not
enlarged. In the lungs - percussion the sound is pulmonary, auscultation - breathing
vesicular, no wheezing, NPV - 17 per minute. Heart sounds are weakened, the rhythm is correct¸
emphasis II tone over the aorta, heart rate - 64 beats per minute, blood pressure - 180/100 mm RT. Art. Tongue
moist, clean, abdominal palpation painless, increased in volume due to
subcutaneous fat. The size of the liver according to Kurlov - 11 × 10 × 6 cm, protrudes by 2
cm from under the costal arch. The gall bladder is not palpable. The spleen is not enlarged.
Pasternatsky’s symptom is negative on both sides. Peripheral pulsation on
arteries of the feet saved, not reduced.
In the general analysis of blood: red blood cells - 4.4 × 10 12 / l, hemoglobin - 142 g / l, CP - 0.85,
leukocytes - 5.6 × 10 9 / l, leukocyte formula without features, ESR - 9 mm / h.
In the general analysis of urine: specific gravity - 1018, no protein, glucosuria ++, white blood cells
- 2-3 in the field of view, red blood cells are absent.
In a biochemical blood test: total cholesterol - 6.9 mmol / l, triglycerides -
3.6 mmol / L, HDL - 0.9 mmol / L, blood glucose - 9.2 mmol / L, HB A1c - 7.6%. ALT - 65
IU / l, AST - 35 IU / l, total bilirubin - 17 μmol / l, direct - 5 μmol / l, indirect -
12 μmol / L. Amylase - 60 units.
Radiography of the lungs - without pathology.
ECG - sinus rhythm, signs of left ventricular hypertrophy, heart rate - 64 strokes per
a minute.
Ultrasound of the abdominal cavity - the liver is enlarged (12 × 10 × 7 cm), unevenly compacted,
“Glistens”, gall bladder is not enlarged, wall 4 mm, suspension, no calculi,
the pancreas is unevenly compacted, not enlarged.
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. Prescribe therapy. Justify your choice.
5. After 6 months of regular therapy - blood pressure ranges from 150-160 / 90-95 mm
Hg. Art., fasting glucose - 5.4 mmol / L, HB A1s - 6.5%, total cholesterol - 4.5
mmol / L, TG - 1.5 mmol / L, HDL-C - 1.2 mmol / L, creatinine - 88 μmol / L,
albuminuria - 10 mg / day. What is your further therapeutic tactic? Justify
Your choice.
Situational task 130 [K000937]
Дата: 2019-12-10, просмотров: 291.