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ANSWERS ON QUESTIONS
Main part
Patient A. 64 years old, a working pensioner (leading engineer of the mine), complains
periodic pain in the epigastrium proper is more on the right 1.5-2 hours after eating,
sometimes at night, heartburn, sour belching. The pains are local, not
they radiate, decrease after dairy food.
Anamnesis of the disease: for 2 years periodically there were pains and heartburn,
which he took with milk, sometimes Maalox and Almagel. Six months ago
was examined, gastroduodenitis was revealed, took Omez 20 mg 2 times and Maalox. During
for three months, clinical manifestations were absent, recently reappeared
and intensified pain, especially at night, heartburn and belching occurred daily. On the eve of
hospitalization was a double vomiting of the contents of the stomach, and then bile. Sick
smokes, last 3 years, 2 packs of cigarettes per day. Work related to per diem
on duty. Father was operated on for gastric bleeding (he does not know the reason).
Objectively: skin of normal color, turgor preserved. Peripheral
lymph nodes are not palpable. Mild without pathological changes. Extended left
border of the heart to the left midclavicular line. The walls of the radial arteries are sealed
(palpated in the form of dense cords). Pulse - 70 beats per minute, high, blood pressure - 130/70 mm
Hg. Art. The tongue is covered in white. The abdomen is involved in breathing. On palpation
notes slight soreness in the right hypochondrium and in the epigastrium proper.
On palpation of the intestine is not changed. Liver along the edge of the costal arch,
vesical 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 - 7.6 × 10 9
/ l, eosinophils - 2%, stab neutrophils - 5%,
segmented neutrophils - 56%, lymphocytes - 37%.
Biochemical blood test: total protein - 82 g / l, total bilirubin - 16.4
(direct - 3.1; free - 13.3) mmol / l, cholesterol - 3.9 mmol / l, potassium - 4.4 mmol / l,
sodium - 142 mmol / l, sugar - 4.5 mmol / l.
FGDS: we pass the esophagus, the cardia outlet closes tightly, the folds of the mucosa
the esophagus is normal. In the antrum of the stomach, foci of edema and bright
hyperemia, as well as single submucosal hemorrhages. KDP bulb
deformed, on the posterior wall of the bulb - an ulcerous scar of stellate character,
on the front wall, a deep ulcerative defect (up to the muscle layer) 10 × 12 mm in size,
significantly increased hyperemic folds of the mucous membrane hang over the defect,
forming an inflammatory shaft. The rest of the mucous membrane of the duodenum with foci
hyperemia.
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 combination therapy? Justify your choice.
5. After 2 months of maintenance therapy, the clinical symptoms of the disease disappeared
completely, with FEGDS at the site of the ulcer, a white scar from the foci of edema and hyperemia
material for a cytological research is taken to a stomach, N. r. is revealed. in the Big
quantity. What is your future tactic? Justify your choice.
Situational task 221 [K002895]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient A., 44, a leading mine engineer, complains of periodic pain in
the epigastric proper, more on the right, which occur 20-30 minutes after eating and
significantly decrease or disappear after 1.5-2 hours. Marks heartburn, sometimes bitterness
in the mouth, appetite is preserved, stool is normal 1 time per day. The patient noted that it is better
carries milk food.
Anamnesis of the disease: for several years noted discomfort in the actual
epigastrium after acidic, smoked, salty food. I took the enzymes indicated
phenomena disappeared. In recent months, I have experienced overwork at work (night shifts),
stresses (pre-emergency situations at the mine). Began to note pain at first dumb
moderate, which were removed by Almagel, milk. In the future, the pain intensified,
especially after eating, regardless of its quality. There was heartburn, which often
accompanied by bitterness in the mouth. Reduced food intake, but pain
progressed, hospitalized in the department.
I smoked ½ pack a day, the last 5 years I have not smoked.
Objectively: the skin is normal color, turgor saved. Peripheral
lymph nodes are not palpable. Mild without pathological changes. Heart borders in
normal. Heart rate - 70 beats per minute, blood pressure - 130/70 mm RT. Art. The tongue is covered in white.
The abdomen is involved in breathing. On palpation notes slight soreness in
epigastrium.
On palpation of the intestines, soreness, volumetric formations are not
revealed. Liver along the edge of the costal arch, cystic symptoms (Kera, Murphy. Ortner)
negative. The spleen is not palpable.
In laboratory and instrumental studies, the following
data.
Complete blood count: hemoglobin - 148 g / l, ESR - 4 mm / hour, red blood cells -
5.2 × 10 12 / l, white blood cells - 7.6 × 10 9 / l, eosinophils - 2%, stab neutrophils - 5%,
segmented neutrophils - 56%, lymphocytes - 37%.
Biochemical blood test: total protein - 82 g / l, total bilirubin - 16.4
(direct - 3.1; free - 13.3) mmol / l, cholesterol - 3.9 mmol / l, potassium - 4.4 mmol / l,
sodium - 142 mmol / l, glucose - 4.5 mmol / l.
FGDS: we pass the esophagus, the cardia outlet closes tightly. Mucous in
esophagus unchanged. In the middle third of the stomach along the lesser curvature there is ulcerative
wall defect (mucous and submucous) up to 1.2 cm, the bottom of the defect is made by fibrin,
the edges of the defect are elevated, edematous. For the rest of the course, there is a lesion in the stomach
mild hyperemia. WPC unchanged. A biopsy of 4 pieces was taken. When taking a biopsy from
edges of the ulcer moderate neutrophilic infiltration and edema.
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 combination therapy? Justify your choice.
5. What recommendations should be given to the patient for the prevention of exacerbation
disease?
Situational task 222 [K002904]
Дата: 2019-12-10, просмотров: 271.