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ANSWERS ON QUESTIONS
Main part
Patient K., 27 years old, a soldier, complains of pain in the right iliac
areas of a permanent nature (often wakes up from pain at night). On this background
periodically there are attacks of pain as colic. Concerned expressed
weakness, weight loss, diarrhea - stool 3-4 times a day in the form of liquid slurry, without
pathological impurities, plentiful. Marks an increase in temperature to 37.6 ° C
daily, especially in the evening.
Anamnesis of the disease: fell ill 1 year ago when suddenly, in the midst of full health
intense pains appeared in the right iliac region, fever up to
38.0 ° C. Delivered to the admission department, where examined by a surgeon, diagnosed with acute
appendicitis. When a blood test revealed leukocytosis, the patient was taken for surgery.
During the audit revealed a thickened ileum with an edematous friable wall,
enlarged mesenteric lymph nodes. The appendix is not changed. Produced
appendectomy. In the postoperative period, hyperthermia appeared up to 38.5 ° С, against the background
the introduction of antibiotics, the temperature decreased to subfebrile numbers, however
not completely gone. Pain in the right iliac region persisted, began to wear
dumb constant character. The patient began to notice more frequent stools, initially up to 2 times per
day, then 3-4, feces initially had the character of a thick porridge ("cow feces"),
then became liquid. In stool, mucus and blood periodically appeared in
a small amount. Weakness gradually increased, during the year of illness the patient lost 6
kg body weight.
Objectively: low nutrition, the skin is somewhat dry, turgor is reduced.
Peripheral lymph nodes are not palpable. Lungs and heart without pathological
changes. Pulse - 80 beats per minute, blood pressure - 110/70 mm RT. Art. Tongue coated in white
in cash. The abdomen is involved in breathing, the usual configuration. On palpation notes
soreness in the right lower quadrant, here the palpable
painful cecum and slightly higher swollen rumbling loops of the small intestine. On
the rest of the pathological changes were not detected. Liver along the edge of the rib
arcs. The spleen is not palpable.
In laboratory and instrumental studies, the following
data.
Complete blood count: hemoglobin - 117 g / l, ESR - 34 mm / hour, red blood cells -
3.2 × 10 12 / l, white blood cells - 12.6 × 10 9 / l, eosinophils - 2%, stab neutrophils - 10%,
segmented neutrophils - 51%, lymphocytes - 37%.
Biochemical blood test: total protein - 52 g / l, albumin - 55%, globulins:
alpha1 - 3.7%, alpha2 - 10.0%, beta - 11.0%, gamma -20.3%. Total bilirubin - 16.4
(direct - 3.1; free - 13.3) mmol / l, glucose - 5.5 mmol / l., cholesterol - 3.9 mmol / l,
potassium - 3.5 mmol / l, sodium - 142 mmol / l, alkaline phosphatase - 310 U / L (normal to 306).
RRS: in the perianal region scars are determined, in one of them fistula with
meager discharge. There are single cracks between the scars. Inspected direct
the intestine and sigmoid, mucous membrane throughout without any pathological changes.
Irrigoscopy: a barium suspension retrogradely fills all parts of the colon and
ileal throughout 15-20 cm. There is uneven narrowing of the distal
ileum and irregular contours, the absence of caustics in the blind and
ascending intestines.
Questions:
1. Formulate the diagnosis in accordance with the classification.
2. Justify your diagnosis.
3. Make and justify a plan for an additional examination of the patient.
4. Which drug group for pathogenetic therapy would you recommend
to the patient as part of combination therapy? Justify your choice.
5. What is the prognosis for this disease?
Situational task 218 [K002891]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient B. 21 years old, a student at a technical university, complains of pain in the right
hypochondrium and epigastrium proper, decreased appetite, nausea, jaundice,
dark urine, subfebrile condition.
Anamnesis of the disease: during the summer holidays traveled along the Ob. To the program
travel included fishing, mushroom hunting, familiarity with the life of the peoples of the North, that
included a tasting of food, mainly consisting of fish of different cooking.
2 weeks after the end of the trip, he began to note discomfort in the right
hypochondrium, fever up to 37.1 ° С, distinct pains appeared in the right
hypochondrium and epigastrium proper, appetite decreased, slight nausea appeared,
urine darkened, others noticed sclera yellowness. Temperature during the day
had a small range of 37.4-37.8 ° C.
He was in Siberia for the first time.
Objectively: a state of moderate severity, a temperature of 37.4 ° C. Skin
integuments and sclera yellow. On the skin are a few areas of the petechial rash,
no calculations. Lungs and heart without pathological changes. The stomach is painful in
right hypochondrium due to an enlarged liver, the right lobe is determined below the rib
4 cm arches, the left lobe is actually the epigastrium, the edge of the liver is rounded,
the surface is smooth, dense-elastic consistency, painful on palpation.
Positive Bubble Symptoms: Kerra, Murphy and Frenicus.
In laboratory and instrumental studies, the following
data.
Complete blood count: hemoglobin - 120 g / l, red blood cells - 4.2 × 10 12 / l, white blood cells -
11.9 × 10 9
/ l, eosinophils - 22%, stab neutrophils - 6%, segmented
neutrophils - 60%, lymphocytes - 10%, monocytes - 2%, ESR - 15 mm / hour.
Biochemical blood test: total protein - 65 g / l, albumin - 55%, globulins:
1 - 3, 2 - 12.2, - 6.3, - 23.5%, glucose - 5.0 mmol / L, total bilirubin - 68 (direct - 50,
indirect - 18) μmol / L, ALT - 50 U / L (normal - 4-42 U / L); AST - 42 U / L (5-37 U / L),
cholesterol - 6.6 μmol / l, alkaline phosphatase - 392 (norm - 64-306), GGTP - 170 U / L (norm 7 - 64 U / L),
blood amylase - 28 g / l (12-32 g / l per hour).
Coprogram: neutral fat +, undigested muscle fibers - units,
fatty acids and soaps + fatty acids, a large number of bacteria. Parasites are not
identified.
Ultrasound of the liver: the liver is enlarged, the size of the right lobe - 169 (normal to 150), the left - 85
(norm up to 70), the structure is homogeneous, echogenicity is reduced, there is an expansion of large
intrahepatic bile ducts.
Rg mild: focal and infiltrative changes were not detected.
FEGDS: in the stomach and duodenum there are areas of hyperemia in the form of stripes.
Virological examination: ELISA: viruses A, B, E - negative.
Questions:
1. State the most probable diagnosis.
2. Justify your diagnosis.
3. Make and justify a plan for an additional examination of the patient.
4. Which drug group for pathogenetic therapy would you recommend
to the patient as part of monotherapy or combination therapy? Justify your
a choice.
5. Indicate the preventive measures for this disease.
Situational task 219 [K002893]
Дата: 2019-12-10, просмотров: 251.