ANSWERS ON QUESTIONS

Main part

Patient M. 36 years old, a salesperson, turned to the local GP

complaints of general weakness, fatigue, hair loss, worsening

memory, decreased interest in life, facial swelling, constipation, lack of menstruation in

within 7 months.

From the anamnesis: considers himself ill for the past year.

The condition gradually worsened, gained 5 kg in weight over the period of the disease.

Objectively: the general condition is satisfactory. Height - 163 cm. Weight - 66 kg.

Body temperature - 36.1 ° C. The skin is pale, dry, peeling is pronounced on the legs.

Pastosity of the face, dense swelling of the feet, lower third of the leg. Rare hair on the head

brittle. Body hair corresponds to the female gender and age.

Peripheral lymph nodes are not palpable. The mammary glands are not changed.

Lactorrhea (++). Above the symmetrical areas of the chest, percussion is determined

clear pulmonary sound. In the lungs, vesicular breathing, no wheezing. BH - 16 per minute.

The area of ​​the heart is not visually changed. The pulse on the radial arteries is rhythmic, weak

filling, symmetrical, 55 per minute, blood pressure - 126/80 mm RT. Art. Relative boundaries

heart dullness: right - 1 cm to the right of the right edge of the sternum, upper - lower edge

III ribs, left - 1.5 cm inwards from the midclavicular line. Heart sounds are muffled

the rhythm is correct, there is no noise, 55 per minute. The tongue is clean, the teeth are imprinted on the tongue.

The abdomen is soft, painless. The palpation of the liver is soft, painless. Dimensions

Kurlov's liver: 9 × 8 × 7 cm. The gall bladder is not palpable. Bubble Symptoms

(Murphy, Kera, Mussey, Ortner) - negative. The lumbar region does not seem to

changed. The symptom of striking is negative on both sides. Not palpable.

The musculoskeletal system without features. The thyroid gland is not enlarged when

examination, upon palpation, tightly elastic, painless, nodular formations not

are determined. Symptoms of Moebius, Kocher, Gref are negative.

In laboratory and instrumental studies, the following

data.

General blood test: red blood cells - 3.2 × 10 12 / l (3.5-4.7 × 10 12 / l), hemoglobin - 101

g / l; ESR - 15 mm / h. General urine analysis: yellow, specific gravity - 1022, protein - neg., Sugar -

neg., epithelium - 2 in the field of view, leukocytes - 0-2 in the field of view, red blood cells - 0-1 in the field

view. Glucose - 4.0 mmol / L; iron - 5.5 μmol / l. TSH - 22.7 μIU / ml, T4 svob. - 6.3

pmol / l; AT to TPO - 250 U / ml (0-30).

Ultrasound of the thyroid gland: V total. - 6.3 cm 3

(8.3-18.0). Increased echogenicity.

The structure is diffuse-heterogeneous.

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 171 [K002018]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient N. 36 years old was admitted as planned to the therapeutic department, with

complaints of dizziness when getting out of bed, severe muscle weakness,

5 kg weight loss over 2 months.

From the anamnesis of life: 2 months ago, against the background of acute respiratory viral infections, the general condition worsened,

I began to worry about general weakness and weakness in the muscles of the arms and legs, growing in the evening,

noted darkening of the skin, decreased appetite.

Objectively: body weight - 54 kg, height - 169 cm. General condition of medium degree

gravity. Diffuse hyperpigmentation of the skin, especially the face, is noted

folds of the neck, palmar folds, postoperative scar after appendectomy.

The oral mucosa is hyperpigmented. The skin is moderately moist. There are no fathers.

The vesicular breathing, no wheezing. BH - 16 per minute. Rhythmic heart sounds, heart rate - 76

beats per minute. HELL - 90/60 mm RT. Art. in a lying position, sitting - 80/50 mm RT. Art. Borders

hearts within normal limits. The abdomen is soft, painless. Liver and spleen not

enlarged. The kidneys are not palpable. The symptom of striking is negative on both sides.

The thyroid gland is not enlarged by palpation, elastic, painless, nodular

formations are not palpable.

Research.

Complete blood count: red blood cells - 3.7 × 10 12 / l, hemoglobin - 120 g / l, white blood cells -

4.0 × 10 9 / l, eosinophils - 4%, basophils - 1%, stab neutrophils - 3%,

segmented neutrophils - 41%, lymphocytes - 48%, monocytes - 3%, ESR - 13 mm / h.

Urinalysis: color - yellow, specific gravity - 1018, protein - 0.01 g / l, sugar - neg.,

epithelium - 1-2 in the field of view, leukocytes - 1-2 in the field of view. Biochemical indicators:

AST - 21 units / L, ALT - 16 units / L, glucose - 3.5 mmol / L, urea - 6.3 mmol / L, calcium - 2.5

mmol / l, potassium - 5.6 mmol / l, sodium - 120 mmol / l, chlorine - 97 mmol / l, creatinine - 98

μmol / l.

ECG: sinus rhythm, heart rate - 79 per min. EOS - vertical. Without pathology.

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 172 [K002021]