ANSWERS ON QUESTIONS

Main part

Patient B. 56 years old was admitted to the hospital with complaints of shortness of breath at rest,

aggravated by the slightest physical exertion (due to shortness of breath, the patient could not

leave the house), cough with purulent sputum, swelling of the legs, heaviness in the right

hypochondrium, an increase in the abdomen. History: 20 years ago, pneumonia. Since

worried cough with sputum, mainly in the morning, the cough intensified in the autumn and

winter time. Periodically, with temperature increases up to 37-39 ° С, he took

antibiotics and sulfonamides. In the last 3 years, shortness of breath began to bother.

Deterioration occurred in the last 4 months, when after a cold and

increase in temperature (up to 38 ° C) for the first time appeared swelling, pain and heaviness in the right

hypochondrium, an increase in the abdomen.

Anamnesis of life. Smokes 25 years for 1 pack of cigarettes per day. Works on harmful

production - in the foundry. I never had tuberculosis before, contact with patients

denies tuberculosis. An allergic history - without features.

The condition is serious, diffuse cyanosis, cyanosis of the lips is expressed. Lean muscle

mass of the upper shoulder girdle. Limbs to the touch are warm, swelling of the legs, hips.

The position in bed is horizontal. The chest is barrel-shaped.

The supraclavicular spaces bulge. Excursion of the chest is limited. At

percussion over the lungs - box sound and lowering of the lower boundaries of the lungs. Breath

weakened, in some areas with a bronchial tinge. At both sides

various wet rales and dispersed dry rales on an exhalation are heard.

BH - 36 per minute. The borders of the heart are normal. Epigastric pulsation, heart sounds

deaf, emphasis II tone on the pulmonary artery. Pulse - 112 beats per minute, rhythmic. HELL -

100/70 mmHg Art. The cervical veins are swollen, especially on exhalation. The abdomen is enlarged in volume.

due to ascites. The liver protrudes from under the costal arch 4-5 cm, elastic, painful

on palpation.

Radiograph - diffuse amplification of pulmonary pattern, horizontal stroke

rib, signs of pulmonary emphysema, flattening of the dome of the diaphragm and restriction

diaphragm mobility during respiratory movements.

ECG: sinus tachycardia, pravogram. Signs of overload right

atrium and right ventricle. Transition zone shift to the left to V4.

Blood test: red blood cells - 5.4 × 10 12 / l, hemoglobin - 174 g / l, color indicator -

1, polychromatophilia, anisocytosis, poikilocytosis, reticulocytes - 3%, leukocytes -

12.5 × 10 9 / l, basophils - 0%, stab neutrophils - 5%, segmented

neutrophils - 61%, lymphocytes - 34%, platelets - 33 × 10 9 / l, monocytes - 9%, ESR - 2

mm / h

Questions:

1. Formulate a presumptive diagnosis.

2. What are the criteria for the main diagnosis.

3. What complications of the underlying disease do you suspect?

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

5. Justify the treatment tactics, the choice of drugs.

Situational task 203 [K002072]

Instructions: READ THE SITUATION AND GIVE EXPLAINED

ANSWERS ON QUESTIONS

Main part

Patient Z. 62 years old with complaints of chills, shortness of breath, delivered to the emergency room

lack of air, extreme weakness. He fell ill acutely 3 days ago when a chill arose,

body temperature increased to 40 ° C, began to disturb dry, and then wet cough with

pink sputum. Progressively increased weakness, shortness of breath,

the cough intensified, during the last days he did not urinate.

On examination, the condition is serious, confused consciousness. The skin is pale,

cool, lip cyanosis, acrocyanosis. Sub-bacterial sclera. Body temperature - 35.8 ° C.

The breath is shallow. BH - 44 per minute. Pulse - 118 per minute, threadlike. Tones

hearts are deaf. HELL - 80/50 mm RT. Art. Over easy shortening of percussion tone in

posterolateral departments of the right lung. In the same sections, breathing is weakened,

moist rales and pleural friction are heard. The abdomen is soft, the liver protrudes

3 cm from under the edge of the costal arch, the margin is soft, moderately painful. Peripheral

no edema.

Blood test: white blood cells - 21 × 10 9 / l, basophils - 1%, stab neutrophils

- 18%, segmented neutrophils - 63%, lymphocytes - 16%, monocytes - 2%, ESR - 58

mm / hour., ACT - 0.7; ALT - 1.28; KShchS: PH - 7,5; P СО2 - 20; P O2 - 50; BE - 10.

Questions:

1. Formulate a presumptive diagnosis.

2. What are the criteria for the main diagnosis.

3. What complications of the underlying disease do you suspect?

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

5. Justify the treatment tactics, the choice of drugs.

Situational task 204 [K002073]