ANSWERS ON QUESTIONS

Main part

Patient P., 54 years old, locksmith, complains of pain in the epigastric region

permanent, aggravated after eating and radiating to

the subscapular space, constant nausea, belching by air, disturbs

decreased appetite, rapid satiety, bloating, after exhaustion of pain gases

decrease for a short time. In the last six months, periodically stool

to diarrhea.

Medical history: often consumes alcohol for 25 years, during this time

acute pancreatitis, accompanied by intense pain, repeated vomiting.

Examination in the surgical department revealed an increase in pancreas

glands in size, fluid in the stuffing bag. Treated conservatively for

months, during the illness lost 10 kg. Discharged with recommendations that the patient

did not comply. Also took alcohol, but in small quantities. Pain arose

often, and later became permanent. Appetite began to decline,

periodic nausea, belching, rapid saturation, as a result of which the patient

reduced the amount of food consumed. Gradually, the chair became prone to

mushy, poorly rinsed off the walls of the toilet. The initial body weight is not completely

scored. Periodically took Mezim, Mikrazim with a partial effect, with amplification

pain used No-shpu. Last worsening 2 weeks ago after a four day

alcohol intake (vodka 200 grams daily). I did not follow a diet. Pain significantly

intensified, there was a distinct nausea, vomiting, bloating.

Hospitalized in the gastroenterological department.

Objectively: the skin is clean, turgor is normal. Weight - 73 kg, BMI - 18.5.

Peripheral lymph nodes are not palpable. Lungs and heart without pathological

changes. Pulse - 90 beats per minute, blood pressure - 110/70 mm RT. Art. Tongue coated in white

in cash. The abdomen is involved in breathing, a little podzud, peritoneal symptoms neg.

On palpation, notes significant soreness in the Shoffar zone, the point of Desjardins;

in the area of ​​Gubergrits - Skulsky, points of Gubergritz, front and back points of Mayo -

Robson.

On palpation of the intestines, soreness, volumetric formations are not

revealed. Liver along the edge of the costal arch, cystic symptoms (Kera, Murphy. Ortner)

are negative. The spleen is not palpable.

In laboratory and instrumental studies, the following

data.

Complete blood count: hemoglobin - 157 g / l, ESR - 4 mm / hour, red blood cells -

5.2 × 10 12 / l, white blood cells - 11.2 × 10 9 / l, eosinophils - 2%, stab neutrophils - 7%,

segmented neutrophils - 56%, lymphocytes - 35%.

Biochemical blood test: total protein - 60 g / l, total bilirubin - 16.4

(direct - 6.1; free - 10.3) mmol / l, amylase - 37 u / l (5-32); glucose - 8.5 mmol / l,

urea - 4.7 mmol / l.

Coprogram: the volume of the morning portion - 400 grams, the consistency in the form of liquid

porridge. Neutral Fat +++, Fatty Acids, Fatty Acids Soaps ++, Muscle

fibers with a lost transverse striation +++, bacteria - a large number.

Fecal elastase - 100 μg / g of feces.

FGDS: we pass the esophagus, the cardia outlet closes tightly. Esophageal mucosa

without changes. The mucous membrane of the stomach in the body is pink, even, in the antrum with foci

bright hyperemia. Bulb of the duodenum of the usual form. The mucosa of the post-bulbar department

KDP is somewhat ottechny.

Ultrasound of the abdomen: there is no abdominal fluid. Pneumatization

the intestines are elevated. The liver is not enlarged, the structure is heterogeneous, increased

echogenicity. The gallbladder is of normal shape, the contents are echo-negative. OSH - 6 mm.

Pancreas: head - 35 mm (up to 30), body - 32 mm (up to 17), tail - 37 mm (up to 20).

The structure is diffusely heterogeneous, of low echogenicity. In the structure of the gland

calcifications are determined, the largest of them in the projection of the pancreatic head

glands. The Wirsung duct is defined in the tail region, 3 mm in size. Spleen

normal sizes.

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. Identify the goals of pathogenetic therapy. Which group of drugs for

pathogenetic therapy you would recommend to the patient as part of

combination therapy? Justify your choice.

5. Indicate measures to prevent exacerbation of the disease.

Situational task 220 [K002894]