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ANSWERS ON QUESTIONS
Main part
Patient I. 54 years old, assistant secretary, turned to an appointment with a general practitioner
a district policeman complaining of hot flashes several times a day amid constant
palpitations, insomnia, tearfulness, intolerance to stuffiness.
From the anamnesis it is known that over the past year after stress, she lost 10 kg. FROM
childhood vitiligo. Menstrual cycle from 15 years to the present, regular, 2
pregnancy and 2 births. On examination: satisfactory condition, sick
emotionally labile, fussy, finely spread tremor of the eyelids, fingers. Weight - 61
kg, height - 170 cm. The skin is elastic, diffusely moist, warm.
There are no peripheral edemas. Hyperemia of the neck, décolleté, depigmented hands. BH
- 16 per minute. Vesicular breathing. Pulse - 118 per minute. Heart tones are loud
the rhythm is correct. HELL - 130/60 mm RT. Art. Liver at the edge of the costal arch. Thyroid
the gland is visible in the eye, enlarged by palpation, elastic, mobile when swallowed,
painless. Symptoms of Moebius, Gref, Kocher, Krause are positive; fatherly
exophthalmos on both sides. Hormonal profile: TSH = 0.05 μIU / ml (0.3-3.2); St. T4 =
76.2 pmol / L (12.3-25.6); AT to TSH receptors = 47 (0). ECG recorded: heart rate - 116 in
minute, sinus rhythm.
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. Make and justify a treatment plan.
5. Assess the prognosis for the patient. Choose a tactic for further observation.
Situational task 168 [K002015]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient P. 31 years old, a geography teacher, was admitted to the department in the direction
general practitioner with complaints of palpitations, insomnia, feeling of heat,
periodic temperature rises to 37.1 ° C, a decrease in body weight of 5 kg.
From the anamnesis it is known that she’s sick for about a year, when she herself began to pay attention
increased irritability, palpitations at night, sometimes insomnia. About
two months I began to feel a rise in temperature to 37.2 ° C, a constant feeling
heat, palpitations during physical exertion. About a month ago appeared
photophobia, a sense of "sand" in the eyes.
Objectively: satisfactory condition, fussy, height - 162 cm, weight - 55 kg.
The skin is flesh-colored, diffusely moist, warm. Subcutaneous fat
fiber is thinned. Fine tremor of outstretched arms, tongue is noted.
Puffiness of the eyelids. The vesicular breathing, no wheezing. The boundaries of the heart are within normal limits.
Heart sounds are loud, the rhythm is correct. Heart rate - 108 per minute, blood pressure - 130/55 mm RT. Art.
Palpation of the abdomen is painless. Liver on the edge of the costal arch. Thyroid
visualized at a distance, diffusely enlarged by both lobes, dense, with uneven
surface, painless, noise is not detected. Symptom of Mѐbius (+) on both
sides, Gref (+), Kocher (-).
In laboratory tests:
general blood test: ESR - 15 mm / hour, hemoglobin - 125 g / l, white blood cells -
5.6 × 10 9 / L; plasma glucose - 6.61 mmol / l, urea - 6.3 mmol / l, total bilirubin -
17.5 mmol / l; cholesterol - 3.3 mmol / L, TSH - 0.035 μMU / ml, T4sv - 40 pmol / L.
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. Make and justify a treatment plan.
5. Assess the prognosis for the patient. Choose a tactic for further observation.
Situational task 169 [K002016]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
A 48-year-old man A., a locksmith, went to the doctor-general
complaints of headaches of a diffuse nature. Hypertension revealed:
HELL sitting - 150/95 mm RT. Art. HELL lying –165/100 mm RT. Art. When examining the fundus:
narrowing of arteries, expansion and tortuosity of venules, arteriovenous crosses
(C-G2), microaneurysms and single point hemorrhages on the periphery; glucose
fasting blood - 10.1 mmol / l, at a random time of the day - 15.0 mmol / l.
From the anamnesis it is known: headaches worry about a year, have not been examined.
Objectively: the condition is satisfactory. Skin color
clean. Fathers, no striae. Mucous clean. OT - 103 cm, OB - 88 cm, weight - 107 kg, height
- 172 cm. BH at rest - 18 per minute. With percussion in the lungs, clear pulmonary percussion
sound. During auscultation, vesicular breathing over all pulmonary fields. HELL - 175/90
mmHg Art., heart rate - 100 per minute. The left border of the heart is expanded 1 cm to the left, the upper and
the right one is normal. The tones are rhythmic, muffled. Tongue coated with white coating, wet.
The abdomen is enlarged due to the fat layer. The liver protrudes from under the costal arch by 3 cm,
the edge is rounded. The symptom of striking is negative on both sides. Urination
not frequent, painless. Chair daily. Diuresis did not count. When viewed from the bottom
limbs: skin of normal color and humidity, clean. Missing
temperature sensitivity on the feet and lower ⅓ lower leg, tactile and pain
sensitivity saved.
Ultrasound of abdominal organs was performed: there is no free fluid. Liver:
the right lobe is 183 mm (CWR: 130-150), the left lobe is 90 mm (CWR 50-60) the contours are smooth,
the structure is diffusely heterogeneous, increased echogenicity. Vascular liver pattern
somewhat impoverished. Intrahepatic bile ducts are not dilated. Gall bladder
ordinary shape, 68 × 28 mm, wall - 2 mm, the contents are echo-negative. ORP - 6 mm (4-6
mm). The pancreas is normal in size, the contours are smooth, clear, structure
diffusely heterogeneous, increased echogenicity. Spleen - 48 cm 2 (up to 50) not
changed.
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. Make and justify a treatment plan.
5. Assess the prognosis for the patient. Choose a tactic for further observation.
Situational task 170 [K002017]
Дата: 2019-12-10, просмотров: 251.