ANSWERS ON QUESTIONS

Main part

Patient M., 30 years old, went to the clinic with complaints of severe pain and

swelling of the joints of the hands, wrist and knee joints, pain when chewing in

mandibular joints, morning stiffness in the joints of the hands until 14-15 hours of the day,

6 kg weight loss in the last 4 months, pronounced general weakness. From the anamnesis:

about 7 months ago, pains in the joints of the hands, wrist, and then

knee joints. I didn’t go to doctors, I took Dicolofenac on my own, and

then nimesulide with some positive effect. Against the background of data reception

drugs there were pains in the epigastrium, heartburn.

On examination: moderate severity. Body temperature 37.4 ºС. Skin

integuments and visible mucous membranes are pale. Changes in the joints of the hands are presented on

figure. In the area of ​​the left elbow joint 2 subcutaneous dense nodules

education size 0.5 × 0.5 cm. Knee joints are configured due to

exudative changes, hyperthermia of the skin is determined by palpation,

positive symptom of balloting of the patella on both sides. DAS 28 = 5.6.

In the lungs, breathing with a harsh tinge, no wheezing. NPV - 17 per minute. Tones

hearts are muffled, there are no noises, the rhythm is correct. Heart rate - 78 beats per minute. HELL - 132/80

mmHg Art. The abdomen on palpation is soft, moderately painful in the epigastrium and

pyloroduodenal zone. The liver and spleen are not enlarged.

In blood tests: hemoglobin - 86.4 g / l, white blood cells - 9.1 × 10 9 / l, platelets - 219

thousand, ESR - 76 mm / hour (according to Westergren).

Protein electrophoresis: albumin - 43.7%, globulins: 1 - 4.9%, 2 - 12.8%, - 12.4%, -

26.2%. CRP - 54.7 mg / l, rheumatoid factor (RF) - 22.1 U / l (normal 0-40 U / l).

Serum iron - 6.2 μmol / L.

Radiography of the hands: periarticular osteoporosis and single cysts in the pineal glands

II-III metacarpal bones on the right, narrowing of the joint spaces of both wrist joints, II-

IV on the left and II-III metacarpophalangeal proximal joints on the right.

Esophagogastroduodenoscopy: bright hyperemia of the antrum mucosa

stomach with 3 erosive defects, mucosal folds are thickened.

Questions:

1. Formulate a detailed diagnosis.

2. Justify your diagnosis.

3. Make and justify a plan for an additional examination of the patient.

4. What basic drug would you recommend as a medicine

first choice means? Justify your choice.

5. Describe the changes in the joints of the hands in the presented figure.

Situational task 140 [K001979]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient D. 56 years old was admitted to the hospital with complaints of the appearance of a strong

headache, dizziness, sensation of a pulsation in the head, nausea, impairment

view. These symptoms first appeared six months ago in the background

stress. She was taken to a hospital where an increase in blood pressure was first detected to

180/120 mmHg Art. It was subsequently observed by a general practitioner, took

antihypertensive therapy. Recently, blood pressure with irregular measurements of 150/80 mm

Hg. Art.

Objectively: general state of moderate severity. Body mass index - 29.7 kg / m 2

.

The face is hyperemic. The vesicular breathing, no wheezing. NPV - 16 per minute. Pulse - 96

beats per minute, blood pressure - 190/90 mm RT. Art. on both hands. Left border relative

cardiac dullness is shifted 1 cm outwards from the midclavicular line. Heart sounds

clear, rhythmic, no noise. The abdomen is soft, painless. The liver is not enlarged.

There are no edemas on the lower extremities.

In a general blood test without pathological changes.

Presented ECG (speed 25 mm / s):

Questions:

1. Assume the most likely diagnosis.

2. What are the abnormalities visible on the ECG presented, and

formulate an ECG conclusion.

3. What syndrome is leading in the clinical picture of this disease?

4. Among which emergency conditions is it necessary to carry out a differential

diagnosis?

5. With the introduction of which drugs should begin the relief of this emergency

condition?

Situational task 141 [K001980]