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ANSWERS ON QUESTIONS
Main part
Patient P. 35 years old turned to a consultative appointment with a general practitioner
a district policeman complaining of drowsiness, weakness, and pastiness of the face,
dry skin, constipation.
From the medical history: these symptoms have been bothering for the past 5
months. Six months ago, she was operated on for diffuse toxic goiter.
(DTZ). Since that time, I haven’t applied to doctors, I haven’t received treatment.
Objectively: the general condition is satisfactory. The skin is dry.
Pastosity of the face, imprints of teeth on the tongue. There are no edemas, striae, hirsutism. At
percussion of lungs over all pulmonary fields defines a clear pulmonary sound.
The vesicular breathing, no wheezing. BH - 16 per minute. Relative cardiac
dullness is normal. Heart sounds are clear, rhythmic. Heart rate - 55 per minute. HELL - 95/70 mm RT.
Art. The abdomen is soft, painless. The liver and spleen are not enlarged. Kidneys not
palpated. The symptom of striking is negative on both sides. On the skin of the neck
postoperative scar. The thyroid gland is not palpable. Lactorrhea
not
The results of the study.
General blood test: red blood cells - 3.3 × 10 12 / l, hemoglobin - 105 g / l, white blood cells -
6.4 × 10 9 / l, eosinophils - 1%, basophils - 1%, stab neutrophils - 3%,
segmented neutrophils - 64%, lymphocytes - 24%, monocytes - 7%, ESR - 10 mm / h.
Urinalysis: color - yellow, specific gravity - 1022, protein - neg., Sugar - neg.,
epithelium - 4 in the field of view, leukocytes - 0-2 in the field of view, red blood cells - 0-1 in the field of view.
Biochemical analysis of blood: sugar - 4.2 mmol / l, AST - 17 units / liter, ALT - 21 units / liter,
Na - 139 mmol / L, K - 4.2 mmol / L, Fe - 4.7 μmol / L.
Ultrasound of the thyroid gland: V ave. Lobes - 0 cm 3 , V lion. shares - 1.1 cm 3 , V total. - 1.1
cm 3 . Normal echogenicity. Diffuse heterogeneous structure, nodular formations
not defined.
ECG: rhythm - sinus bradycardia, heart rate - 56 per minute, EOS horizontal.
Moderate metabolic changes in the myocardium. Hormonal profile and definition
antibodies: TSH - 19.8 μIU / ml, T4 free. - 7.0 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 173 [K002022]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient V., 45 years old, was admitted to the hospital as a physician
local. Concerned about headaches, flashing flies before the eyes, constant
thirst, rapid urination, lower back pain, severe weakness, change
appearance.
From the anamnesis: over the past 5 years after the cessation of menstruation noticeably
appearance has changed: the face has turned red and rounded, limbs have grown thinner, has increased
in the volume of the stomach, dry skin became, the hair on the head became thinner, a mustache appeared.
It was observed by a neurologist for 3 years in connection with lower back pain, which
treated as osteochondrosis. For 2 years was observed by a general practitioner
precinct about hypertension (maximum blood pressure - 170/100 mm RT. Art.)
Objectively: height - 175, weight - 110 kg, BMI - 35.9 kg / m 2 . The patient looks
significantly older than their age, there is a redistribution of subcutaneous fat
fiber, its excessive deposition in the region of the VII cervical vertebra, in the supraclavicular
areas on the chest and abdomen. The skin is dry, "marble", thinned, many
hemorrhage; on the elbows, abdomen, in the armpits - hyperpigmentation. On the hips
- crimson-red wide striae. In the lungs, vesicular breathing, no wheezing. BH - 17 in
a minute. The borders of the heart are extended to the left. Heart sounds are muffled, rhythmic. Heart rate -
92 per minute. HELL - 190/100 mm RT. Art. The abdomen is soft, painless, enlarged due to
subcutaneous fat. The liver along the edge of the costal arch, painless.
Laboratory research. General blood test: red blood cells - 5.3 × 10 9 / l,
hemoglobin - 135 g / l, white blood cells - 10.2 × 10 9 / l, stab neutrophils - 10%,
segmented neutrophils - 76%, lymphocytes - 12%, monocytes - 2%, eosinophils -
0%, ESR - 3 mm / h.
Biochemical analysis of blood: glucose - 7.7 mmol / l, K + - 2.5 mmol / l, Na - 170
mmol / L, cholesterol - 5.7 mmol / L, Ca - 3.6 mmol / L, ALT - 34 IU, AST - 42 IU, total
protein - 57 g / l.
Urinalysis: reaction - alkaline, specific gravity - 1025, sugar ++, protein -
0.25, white blood cells ++.
ECG: rhythm - sinus, heart rate - 84 per minute. The electric axis is horizontal.
LV hypertrophy. Dystrophic changes in the myocardium of the left ventricle.
X-ray examination of the skull and spine revealed
pronounced osteoporosis of the back of the Turkish saddle, osteoporosis of the bones of the spine.
MRI shows a diffuse increase in both adrenal glands.
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 174 [K002023]
Дата: 2019-12-10, просмотров: 254.