4. Make a treatment plan.

Answer

1. Acute viral hepatitis of mixed etiology (B + C), icteric form, severe course in a patient with liver toxicity (heroin addiction). Preliminary diagnosis is made on the basis of epidemiological data (intravenous drugs), clinical manifestations (the cyclical course of the disease, preicteric period, dyspeptic and asthenic-vegetative syndrome, jaundice, enlarged liver and spleen), and taking into account the detection of HBsAg and anti-HCV have patients with high hyperenzymemia and hyperbilirubinemia. On the severity of acute viral hepatitis show severe symptoms of liver cell failure (increasing weakness, disturbed sleep rhythm, dizziness, nausea, vomiting and lack of appetite, low prothrombin index).

2. Clinical and biochemical signs indicate a high probability of joining the delta infection in patients with HBsAg and anti-HCV (preicteric short period, accompanied by a fever, which is stored on the background of the appearance of jaundice, perverted coefficient de Rytis - prevalence levels of AST ALT, severity course of the disease).

3. In a patient with acute hepatitis syndrome revealed mixed infection, simultaneously discovered markers of hepatitis B and C (HBsAg and anti-HCV). To clarify the etiology of the disease is necessary to study markers and replication HBV(anti-HBc IgM, anti-IgM and IgC delta). The following options are available:

4. - The absence of anti-HBc IgM in a patient with HBsAg and anti-HCV antibody detection agent to the delta-delta diagnosed acute infection (superinfection) of the carrier HBV infected with HCV;

5. - In case of detection of markers of HBV replication (IgM anti-HBc) in a patient with HBsAg, and anti-HCV antibodies to the delta agent is diagnosed acute viral hepatitis delta agent (co-infection) in a patient infected with HCV;

6. - In the presence of anti-HBc IgM in a patient with HBsAg and anti-HCV and the absence of antibodies to the delta agent diagnosis "acute hepatitis delta agent without" is placed in the dynamics of disease in a patient infected with HCV;

7. - In the absence of replication HBV markers (anti-HBc IgM) in the patient with HBsAg and anti-HCV antibodies in the absence of a dynamic deltaagentu disease diagnosed "acute hepatitis C" in HBsAg carrier.

8. 4. Therapeutic measures should include strict bed rest, fractional, excessive drinking up to 2 liters per day, daily cleaning enema and reception is poorly absorbed broad-spectrum antibiotics to suppress intestinal microflora. Appointed as lactulose 15.0 3 times a day inside. Showed a strict account of urine output, a negative value is recommended diuretics (furosemide (Lasix *) veroshpiron). For the prevention of hemorrhagic syndrome introduced vikasol * by 3.0 intramuscularly 1 time per day, etamzilat (Dicynonum *) by 2.0 3 times a day intramuscularly, orally administered ranitidine 150 mg / day, almagel * 15.0 3-4 times per day, is carried dezintok- sikatsionnyh intravenous infusion solutions, which is determined by the amount of renal excretory capacity, but generally does not exceed 2.0-2.5 liters per day (polarizing solution - 10% glucose solution 400.0 8 units of insulin and 4.5% solution of potassium chloride - 20.0, physiological saline, with an increase in hepatic failure and reducing the prothrombin - fresh frozen plasma, albumin).

Task 6

The patient, aged 49, an engineer, a doctor sent to clinics in the consultative hapatic center with a diagnosis of "chronic hepatitis C". At clinical examination revealed an enlarged liver and spleen, reduced levels of platelets in the peripheral blood to 80,0h109 / l. Serum antibodies to the NSO, ALT - 46 U / L, AST - 32 IU / L, bilirubin - 18 mmol / l.

From epidemiological history: During several years, I was the donor blood and plasma, but in 1995, was withdrawn from the donation due to an increase in blood ALT and 3 standards with HB sAg serum was observed. In subsequent years, the doctor did not appeal and was not surveyed. Alcohol during that time consumed 3-4 times a month, 200,0-400,0 grams of vodka.

On examination: the patient's state of health is satisfactory, said the poor tolerance of even small doses of alcohol. The skin is clean, palmar erythema, jaundice is not, on the neck, chest, back and on the dorsum of both hands "spider veins" (12) with a diameter of 5 mm to 2 cm, peripheral edema is not detected, the front surface of the tibia in the lower third on both sides - trophic disorders in the form of hyperpigmentation. Language bright red buds smoothed. Abdomen increased in volume due to free liquid percussion defined in sloping areas palpation soft, painless in all departments. The liver is enlarged, its edge protrudes from under the right hypochondrium 3 cm in the midclavicular line, texture dense, sharpened edge. The spleen is enlarged, dense. Peristalsis active small rumbling along the colon palpation. Consciousness is clear, calm, adequate, oriented in space and time, psychometric test is performed quickly and correctly.

Total protein - 75 g / l, albumin - 36 g / l, y-globulins - 24%, prothrombin index - 63%.

1. Put the preliminary diagnosis and justify it.

2. What additional methods of inspection are necessary in this case?

3. Make a plan for the patient's treatment.

Answer

1. HCV with the outcome of cirrhosis (class A on a scale Child Pugh); hepatosplenomegaly, portal hypertension, ascites, thrombocytopenia. The diagnosis is suggested by clinical and laboratory signs (large and severe liver and spleen density, the presence of secondary hepatic signs - "spider veins", palmar erythema, "cardinal" of the language, ascites, thrombocytopenia, hyper- gammaglobulinemia, serum detection of antibodies to HCV), as well as data epidemiological history (of donors), diseases of the prescription (increased ALT levels in 1995). Perhaps HCV has not been verified in 1995, due to the fact that at the time of the test system for the detection of antibodies to NSO were not available in all hospitals.

2. The ultrasound of the abdomen, esophagogastroduodenoscopy, and the level of AFP.

3. Hospitalization. bedrest. Table number 5, limiting the water load (up to 1 liter per day), the exclusion from the diet of salt. Cleansing enema. Accounting diuresis. Lactulose 15.0 3 times daily by mouth, veroshpiron 100 mg 3 times a day, a polarizing solution - 10% glucose solution - 400.0 insulin - 8 IU and 4.5% potassium chloride solution - 20.0 intravenously 20 % albumin solution - 200.0 2 times a week intravenously.

Task7

The patient, 69 years old, a mechanic, was in the gastroenterological department with a diagnosis of "exacerbation of duodenal ulcer, chronical hepatitis C". There was a significant weight loss over the last 9 months (16 kg). Abusing alcohol for 20 years, weekly drinks about 750,0-1000,0 grams of vodka. CHC diagnosed 13 years ago.

From the epidemiological history: received repeated blood transfusion in 1979 and 1982. due to gastrointestinal bleeding (peptic ulcer suffering from 18 years of the duodenum).

Dimensions small liver (palpation is determined by the edge of the costal arch), the spleen is not enlarged. The hemogram - anemia (Hb - 96 g / l) and Uwe-crease ESR 56 mm / h. Serum antibodies to the NSO, ALT - 28 U / L, AST - 23 IU / L, bilirubin - 13 umol / L, increased GGT 40 times, a-fetoprotein - 130 times. Ultrasound of the liver in the right lobe formation found 3,2x2,1 cm with fuzzy contours.

1. What kind of disease is all about?

2. What are the risk factors for an unfavorable course of chronic hepatitis C are at present

patient?

4. Consultation of what experts need?

Answer

1. hepatocellular carcinoma in patients with CHC.

2. Alcohol abuse - a factor of adverse outcome of HCV.

3. Consultation of the surgeon, the oncologist to decide on the possibility of surgical treatment

HIV infection

Task 1

The patient, 35 years, appealed to the clinic with complaints of fever up to 37.5 ° C, sore throat, nasal congestion. Acutely ill 2 weeks ago, she was treated with folk remedies - without pronounced effect. Physician clinics during the inspection noticed a significant increase in the occipital, submandibular, axillary, and even elbow lymph nodes, flushing back of the throat, a moderate increase in the tonsils, nasal breathing difficulty, moderate increase and liver tenderness on palpation. When collecting epidemiological history revealed that the patient for 3 months has sexual partner - the unemployed, previously long-drug users. The doctor has appointed laboratory examination (reaction Hoff-Bauer and research for HIV antibodies). The patient again came to the reception of a week: the body temperature of 37 ° C, the lymph nodes are still enlarged, saved sore throat, shortness of nasal breathing. In the blood, antibodies to HIV. The doctor hospitalized patients diagnosed with "AIDS".