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ANSWERS ON QUESTIONS
Main part
Patient M., 46 years old, was admitted to the hospital as a physician
district district clinic. Concerned about headaches, flashing flies before
eyes, constant thirst, rapid urination, lower back pain, worse
when moving, sharp weakness.
From the anamnesis: the last six months I began to note changes in appearance: rounded
face, limbs have lost weight, stomach has increased in volume, dry skin is disturbed,
hair loss on the head. Turned to a neurologist in connection with back pain.
Recently, there has been an increase in blood pressure - up to 220/110 mm Hg. Art., takes enalapril 5
mg × 2 r / day.
Objectively: a satisfactory condition, height - 161 cm. Weight - 95 kg. BMI = 36.7
kg / m 2 . The patient looks much older than his years, there is a redistribution
subcutaneous fat: its excessive deposition in the cervical region VII
vertebra, in the supraclavicular areas, on the chest and abdomen. The skin is dry, "marble",
thinned. On the abdomen there are purple-red broad striae. In the lungs, vesicular breathing,
no wheezing. BH - 17 per minute. The borders of the heart are extended to the left. Heart sounds
muffled, rhythmic. Heart rate - 88 per minute. HELL - 190/100 mm RT. Art. The stomach is soft
painless, increased due to subcutaneous fat. 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 results.
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 - 73%,
lymphocytes - 12%, monocytes - 4%, eosinophils - 1%, ESR - 3 mm / h.
Biochemical analysis of blood: glucose - 11.2 mmol / l, K + - 3.1 mmol / l, Na - 140
mmol / L, cholesterol - 5.7 mmol / L, Ca - 3.6 mmol / L, ALT - 34 IU, AST - 33 IU, total
protein - 67 g / l. Urinalysis: reaction - alkaline, specific gravity - 1025, sugar ++,
protein - 0.03, leukocytes - 1-2 in the field of view, epithelium - 2-3 in p / vision.
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 of the thoracic and lumbar spine: bone osteoporosis
the spine.
Ultrasound of the adrenal gland: the right adrenal gland is significantly increased in volume.
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 175 [K002024]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient K., 60 years old, turned to a consultative appointment with a general practitioner
a district policeman complaining of constipation, hoarseness, memory loss,
weakness, drowsiness, face pastiness, hair loss, dry skin.
From the anamnesis it is known: these symptoms are disturbing for the past 12
months.
Objectively: the general condition is satisfactory. The skin is dry,
hyperkeratosis of the elbows. Pastosity of the face, moderate dense swelling of the lower extremities
(feet, ankle joint, upper third of the leg). Striae, no girutism. At
percussion of lungs over all pulmonary fields defines a clear pulmonary sound.
The vesicular breathing, no wheezing. BH - 15 per minute. Relative cardiac
dullness is normal. Heart sounds are muffled, rhythmic. Heart rate - 60 per minute. HELL - 110/70
mmHg 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. Thyroid
palpation is not enlarged, painless, nodular formations are not determined.
No lactorrhea.
Research results.
General blood test: red blood cells - 3.8 × 10 12 / l, hemoglobin - 122 g / l, white blood cells -
5.9 × 10 9 / l, eosinophils - 2%, basophils - 1%, stab neutrophils - 3%,
segmented neutrophils - 63%, lymphocytes - 26%, monocytes - 5%, ESR - 11 mm / h.
Urinalysis: color - yellow, specific gravity - 1021, protein - neg., Sugar - neg.,
epithelium - 2 in the field of view, leukocytes - 0-1 in the field of view, red blood cells - 0-1 in the field of view.
Biochemical analysis of blood: sugar - 4.4 mmol / l, AST - 16 units / liter, ALT - 19 units / liter,
Na - 142 mmol / L; K - 3.9 mmol / L.
Ultrasound of the thyroid gland: V ave. Lobes - 3.0 cm 3 , V lion. shares - 2.1 cm 3 , V total. - 5.1
cm 3 . Echogenicity is increased. Pronounced diffuse heterogeneous structure, nodal
formations are not determined.
ECG: rhythm - sinus bradycardia, heart rate - 59 per minute, EOS vertical.
A moderate decrease in the voltage of the teeth is determined. Moderate metabolic
myocardial changes.
Hormone profile and antibody determination: TSH - 26.7 μMU / ml.
T4 svobod - 6.1 pmol / L, AT to TPO - 271 U / ml, AT to thyroglobulin - 310 μg / ml.
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 176 [K002026]
Дата: 2019-12-10, просмотров: 246.