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ANSWERS ON QUESTIONS
Main part
Patient G., 55 years old, was admitted to the hospital with complaints of severe shortness of breath
mixed nature with little physical activity and even when dressing,
cough with yellow viscous sputum up to 150 ml / day, palpitations, weakness, sweating. IN
for 15 years, a cough with sparse mucous sputum, mainly in the morning, has been bothering
I did not consult a doctor about this. The last 7 years there was shortness of breath when walking on
a distance of about 500 meters on the exhale, in cold weather it feels difficulty exhaling and
"Whistles" in the chest. Independently takes Eufillin inside. Deterioration 5
days ago, when shortness of breath sharply increased after SARS, the night slept sitting, increased
amount of sputum.
He works as a driver. Smokes. The smoking index is 120 pack-years. Drink alcohol
2 times a month a little. Allergic and blood transfusion history not
burdened.
The condition is serious. The skin is moist, cyanosis of the lips and tip of the nose. Temperature -
36.8 ° C. The subcutaneous fat layer is poorly developed. Swelling of the legs to the middle third.
Peripheral lymph nodes are not enlarged. The chest is symmetrical, evenly
involved in breathing. BH - 28 per minute. Percussion sound mosaic. On auscultation
all pulmonary fields have a mass of dry rales. The borders of the heart are extended to the right. Tones
rhythmic hearts, heart rate - 120 per minute, on the pulmonary trunk - emphasis 2 tones. HELL - 130/70
mmHg Art. The tongue is clean, moist. The abdomen is soft, painless on palpation. Liver
protrudes 3 cm from under the edge of the costal arch, the spleen is not palpable. Symptom
striking negative on both sides.
General blood test: red blood cells - 5.4 × 10 12 / l; hemoglobin - 177 g / l; white blood cells -
10.6 × 10 9 / l; eosinophils - 0%; basophils - 0%; stab neutrophils - 5%;
segmented neutrophils - 70%; lymphocytes -20%; monocytes - 5%. ESR - 22 mm / hour.
Chest x-ray: focal and infiltrative changes
not defined. The pulmonary pattern is deformed. The roots are expanded, structureless.
The diaphragm is located usually, the sines are free. The trunk of the pulmonary artery swells.
Spirogram: Tiffno index - 65; FEV1 after BDT - 29%.
KShchS: pO 2 - 46 mm RT. Art., SaO 2 - 78%.
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. Which group of drugs would you recommend as an emergency and
as a basic therapy for the treatment of COPD? Justify your choice.
5. After 6 months of regular therapy, the patient quit smoking, noted a decrease
shortness of breath, stopped swelling. On examination, hepatomegaly is not detected. BH - 24 in
a minute. In lungs during auscultation, single dry rales. FEV1 - 32% of
due value, the Tiffno index is 64%. Peak expiratory flow rate - 35% of
due size. KShchS - pO 2 , 70 mm RT. senior, SaO 2 - 90. What is your future
treatment tactics? Justify your choice.
Situational task 223 [K002906]
Instructions: READ THE SITUATION AND GIVE EXPLAINED
ANSWERS ON QUESTIONS
Main part
Patient A., 34 years old (does not work), was admitted to the clinic with complaints of an increase
body temperature up to 38.4 ° C, accompanied by intense night sweats;
chills; swelling of the legs, an increase in the volume of the abdomen, pain in the right hypochondrium,
point rashes on the legs.
From the anamnesis: smokes for 20 years up to 2 packs of cigarettes per day, during the last
2 years suffering from injecting drug addiction. Heredity is not burdened. Of
transferred diseases marks scarlet fever in childhood. No allergic history
burdened. Considers herself ill for a month and a half, when she began to celebrate
increasing weakness, night sweats, fever up to 38.4 ° C,
accompanied by chills. I didn’t ask for help. Independently accepted
antipyretic. Over the past two weeks, noted an increase in edema on
legs, an increase in the volume of the abdomen, the appearance of pain in the right hypochondrium.
Objectively: moderate state, body temperature 37.8 ° C, skin
integument pale with icteric shade, on the skin of the lower extremities elements
hemorrhagic rash, swelling of the feet and legs. Lymph nodes are not palpable. IN
easy breathing hard, no wheezing. Percussion sound clear lung, local
dullness is not detected. With percussion of the heart, the right border is 4 cm to the right of the right
edges of the sternum, other borders within normal limits. During auscultation, heart sounds
rhythmic, heart rate - 110 per minute, there is a weakening of the first tone over the xiphoid
process. Here, systolic murmur is heard, amplified by inspiration.
Swollen cervical veins are noted. The abdomen is tense, painless, positive.
symptom of fluctuations. Liver +5 cm from the edge of the costal arch. The edge is rounded
soft elastic consistency. The edge of the spleen is palpated. Symptom of striking
negative on both sides.
In laboratory and instrumental studies, the following
data.
Complete blood count: hemoglobin - 104 g / l, red blood cells - 3.8 × 10 12 / l, white blood cells -
17 × 10 9 / l, stab neutrophils - 7%, segmented neutrophils - 80%,
lymphocytes - 9%, monocytes - 3%, eosinophils - 1%, ESR - 48 mm / h.
Urinalysis: yellow, transparent, normal pH, specific gravity - 1016,
protein - 0.02%, no sugar, white blood cells - 1-2 in the field of view, no red blood cells.
Biochemical blood test: bilirubin - 38.2 mmol / l, AST - 74, ALT - 98,
creatinine - 0.108 mmol / l, glucose - 5.7 mmol / l, cholesterol - 5.0 mmol / l, potassium - 4.2
mmol / l.
Hemoculture: in one of the 3 samples, the growth of Staphylococcus aureus.
ECG
Chest x-ray
Questions:
1. Select the syndromes and justify them (explain the pathophysiological mechanism of their
occurrence).
2. Formulate a diagnosis.
3. Justify your diagnosis.
4. Make an examination plan to clarify the diagnosis.
5. Define a treatment plan.
Situational task 224 [K002907]
Дата: 2019-12-10, просмотров: 259.