Клинические задачи по дисциплине «Внутренние болезни» (на английском языке) = Clinical Cases in Internal Diseases Specialty (in English). Учебно-метод

SECTION 2

Task 1

A 23-year-old man without bad habits, complains of general weakness, fever up to 39°C, dry cough that occurs after overcooling.

PE: temperature is 38.5 °C. Respiratory rate: 18 breaths per minute. The chest is not visually changed. Vocal fremitus is not changed. Percussion sound above the lungs is clear. Breathing is hard with scattered dry, wheezing buzz.

Complete blood count: white blood cells = 10.4x109 /L. Neutrophils = 88% (bands - 7%). ESR = 38 mm/h, C-RP = 75 mg/L.

Pulmonary Function test (PFT): FEV1 – 68% of predicted, FVC – 94% of predicted, FEV1/FVC = 64%.

Chest X- ray: normal variant.

Leading syndrome (s)?

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Presumptive diagnosis?

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Task 2

The patient is a 57-year-old man. He has been a smoker for 35 years, 1.5 packs per day. He complains of general weakness, fever up to 38°C, and cough with mucopurulent sputum especially in the morning, and shortness of breath with minimal physical exertion.

History: about 5 days ago, cough and breathlessness intensified and there was increase in amount of sputum, with it acquiring purulent character.

PE: temperature 37.5 °C. He is sitting, resting his hands on the edge of the bed. Skin and mucous are cyanotic. RR is 24 breathes per min. Barrel-shaped chest. Decrease in vocal fremitus symmetrically on both sides. Percussion: box sound. Breathing is labored and dry variegated wheezing is heard on both sides.

Complete blood count: leucocytes 14.3x109 /L, neutrophils 81% (bands 8%). ESR 42 mm/h.

Chemistry: C-reactive protein 51.4 mg/L; Fibrinogen 8.1 g/L. Pulmonary Function Tests: FEV1- 56% of predicted; FEV1/FVC - 65%; negative test with Salbutamol (FEV1 increase of 2%).

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Chest X-ray: shows increased transparency of lung pattern; focal infiltration is not revealed.

Leading syndrome (s)?

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Presumptive diagnosis?

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Task 3

An 18-year-old female patient complains of daily attacks of suffocation, cough, difficulty exhaling, with the discharge of viscous glassy mucous upon contact with a cat, when cleaning, when falling asleep and when feeding the aquarium fish; night attacks 5-6 times a week, limitation of physical activity due to shortness of breath.

History: the complaints bothered her for 6 months. Polyvalent allergy. Her grandmother also reported suffocation attacks. She suffers from chronic sinusitis.

PE: Respiratory rate - 18 breaths per min. The chest has normal shape. Vocal fremitus is preserved on both sides, percussion sound is clear lung, and mobility of the lower edge of the lungs is 6 cm. On auscultation, there are weakening of vesicular breathing with prolonged expiration, and dry wheezing heard above all pulmonary fields.

Complete blood count: eosinophils 18.1%. Blood test for IgE is: 1900 kU/L.

Pulmonary function tests: FEV1 - 64% from predicted normal value, FEV1/FVC - 65%, increase in FEV1 after 400 mkg of Salbutamol inhalation - 33%.

Chest X-ray: normal variant

What is (are) the leading syndrome (s)?

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What is the supposed diagnosis?

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Task 4

A 55-years-old male patient complains of paroxysmal cough with difficult expectoration of viscous mucous during the day and night hours, dyspnea with labored breathing, limiting physical activity.

History: the deterioration of condition began with the beginning of the repairs at work (the smell of paint).

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PE: noisy breathing, the patient is sitting with his hands on the edge of a chair. Diffuse cyanosis. Barrel-shaped chest, over-and subclavian region flattened, widened intercostal spaces, dilation of the neck veins, auxiliary muscles participate in breathing, retraction of the intercostals spaces. Vocal fremitus is weakened. On percussion: box sound, lower border of the lung at the medial axillary line is determined at the level of 9th ribs, lungs tour along this line 2 cm. At auscultation of the lungs, dry rales are heard in large quantities in the background of hard breathing. RR is 28 breaths per min. Cardiac sounds are rhythmic, muffled. BP is 120/70 mm Hg, pulse 96 beats/min.

Complete blood count: white blood cells 8,2x109/L, 8.5% eosinophils, erythrocyte sedimentation rate 12 mm/h.

Immunoglobulin E: 1500 kU/L.

Pulse oximetry: arterial oxygen saturation is 89%.

The general analysis of sputum: transparent, viscous, glassy, white blood cells - 20 p/sp, eosinophils - 20-35 p/sp, Kurshman spirals++, Charcot-Leyden crystals +++, BC and atypical cells are not found.

PFT: FEV1 = 27% of predicted, FEV1 / FVC = 56%

Chest X-ray: visualization of increased transparency of lung pattern on both sides, infiltrative changes have not been identified.

What is (are) the leading syndrome (s)?

______________________________________________

What is the supposed diagnosis?

___

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Task 5

A 50-year-old female patient complains of a headache, hyperthermia, sharp stabbing pain in the left half of the chest, which intensifies with coughing, breathlessness, and cough with rusty sputum.

History: the illness started acutely after overcooling.

PhE: temperature =39.4°C; general condition of patient is severe, face is hyperemic, on the lips, there had been determined herpes rash. RR is 30 breaths per minute. Upon inspection, right half of chest lags during respiration. Upon palpation, vocal fremitus is increased on the right. Upon percussion on the right below the lower lobes, a dull sound has been determined. Upon auscultation, there is bronchial breathing, and

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in the same place, crepitation is heard. Heart rate is 92 beats per minute. BP is 100/70 mmHg.

Total blood count: leucocytes= 15.6x109/L; neutrophils 85% (bands- 7%); ESR=63 mm/h.

Pulse Oximetry: arterial blood oxygen saturation= 92%.

Biochemical analysis of blood: C-reactive protein =22mg/L; fibrinogen=8g/L.

Sputum culture: Streptococcus pneumonia 108. Chest X-ray: infiltration in the right lower lobe.

Leading syndrome (s)?

______________________________________________

Presumptive diagnosis?

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Task 6

A 20-year-old male patient complains of general weakness, fever, and cough with yellow sputum.

History: he fell ill 10 days ago with appearance of a runny nose, a cough and a headache. He took antipyretics without prescription. His condition deteriorated yesterday with fever up to 38.4°C.

PhE: the chest examination did not reveal detectable changes. RR =24 breaths per minute. Below the angle of the right scapula, there is increased vocal fremitus, dullness on percussion and, on auscultation weakened vesicular breathing and moist fine rales are heard.

Complete blood count: leucocytes =18.1x109/L; neutrophils=91% (bands – 6%); ESR= 55mm/h.

Biochemical analysis of blood: C-reactive protein =15mg/L; fibrinogen = 9g/L.

Sputum culture: Haemophilus influenza 108.

Chest X-ray: two foci of infiltration in the right lower lobe.

Leading syndrome (s)?

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Presumptive diagnosis?

______________________________________________

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Task 7

A 30-year-old female patient complains of hyperthermia up to 39°C in the past 5 days, heaviness in the right half of the chest, cough with a small amount of sputum and breathlessness.

PhE: RR = 26 breaths per minute; right half of the chest lags during respiration, and there is a sharp weakening of vocal fremitus and shortening of percussion sounds. On auscultation of the right in the middle region of the lungs, there is diminished breathing and in the lower regions breathing is not detected.

Complete blood count: leucocytes =12.8x109/L.; neutrophils =84% (bands – 5%), ESR=59 mm/h.

Analysis of pleural fluid: relative density=1.018.; color: yellow, turbid; Rivalta reaction: positive. Proteins: 47 g/L. LDH=380 IU/L. Leucocytes (neutrophils) =82%.

Chest X-ray: effusion up to the top edge of 4th ribs on the right.

Leading syndrome (s)?

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Presumptive diagnosis?

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Task 8

A 39-year-old male patient with alcohol abuse, complains of pain in the left half of the chest, aggravated by deep breathing, cough with profuse purulent sputum with odor, fever up to 39°C with chills, shortness of breath, palpitations and sharp general weakness.

History: fell acutely ill a week ago after overcooling.

PhE: temperature=37.8°C; BMI=16.5 kg/m2. RR= 26 breaths per minute. Left half of the chest lags during respiration. Breath sounds are increased in the projection below the left corner of the scapula. On percussion, at the same place, tympanic sound is determined. On auscultation: wet, bubbly rales with background bronchial breathing.

Complete blood count: leucocytes =20.4x109/L.; neutrophils= 91% (bands – 7%). ESR =90 mm/h.

Biochemical analysis of blood: C-reactive protein=36 mg/L. Fibrinogen =18 g/L.

ECG: Sinus tachycardia. Heart rate: 105 beats per minute

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Sputum culture: Staphylococcus aureus 108. No sensitivity to Penicillin and Ampicillin. Has Sensitivity to Vancomycin and Cephalosporin IV generation.

Chest X-ray: on the left, on the background of non-homogenous infiltration rounded opacities with the liquid level.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 9

A 46-year-old patient complains of general weakness, malaise, reduction of work capacity, deterioration of appetite, loss of weight (wasting), and cough with little amounts of sputum.

History: lost 6kg in 3 months. Smokes 20 cigarettes for 30 years. PhE: temperature =36.9°C; BMI 21 kg/m2. RR = 20 breathes per minute. The Palpable right supraclavicular, axillary lymph nodes with a size of up to 1 cm, were dense, painless, fused to surrounding tissues. There is increased vocal fremitus and dullness in the angle of the right scapula. In the same place, breathing is weakened, and there are isolated wet rales.

Complete blood count: erythrocytes = 2.7x1012/L; hemoglobin = 83 g/L, Mean Corpuscular Volume (MCV) = 71fL, Mean Corpuscular Hemoglobin (MCH) = 23 pg, ESR= 100 mm/h.

Biochemical analysis of blood: Total protein=59g/L, C-reactive protein=26 mg/L

Sputum Analysis: atypical cells, erythrocytes

Chest X-ray: it shows a roundish formation with indistinct borders in the projection of the segment S6, hilar lymph nodes.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 10

A 36 year-old-male patient complains of chills, fever, dry cough, severe pain in the right side of the chest when breathing, coughing.

PhE: body temperature - 37,8 °C, the patient is lying on his right side to reduce the pain. The skin is clean. Lagging of the right half of the chest during breathing was observed. RR is 18/min. Palpation of the chest revealed pain in the lower right corner of the scapula, vocal fremitus is not changed, and percussion sound is not changed. Breathing on right side is weakened to some extent, pleural rub is heard.

Complete blood count: white blood cells 13,2x109/L, 83% neutrophils (bands - 7%), erythrocyte sedimentation rate 49 mm/h.

Biochemical analysis of blood: C-reactive protein, 26 mg /L fibrinogen, 12 g / L.

Chest X-ray: changes in the pulmonary pattern is not revealed, the compaction of the interlobar pleura.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 11

A male patient of 26 years complains of fever, non-productive cough, heaviness in the left side of the chest, progressive dyspnea.

History: the second week is sick.

PhE: a body temperature is 37,8 °C. RR of 28/min. On examination of the chest: bulging and lagging the left half with breathing, there is a sharp weakening of the vocal fremitus, dull percussion sound below 4th intercostal space. Breathing in this area sharply reduced. Above 4 ribs there is an increase in vocal fremitus, dullness in percussion, bronchial breathing upon auscultation.

Complete blood count: white blood cells 15,2x109/L, 77% neutrophils (stab - 9%), erythrocyte sedimentation rate 52 mm/h.

Biochemical analysis of blood: C-reactive protein, 115 mg/L, 24 g of fibrinogen/L.

Chest X-ray: shows a sharp decline in pulmonary transparency in the left lung pattern on the left below the 4th ribs.

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What is (are) the leading syndrome(s)?

______________________________________________

What is the assumed diagnosis?

______________________________________________

Task 12

A 52-year-old male patient was bothered by shortness of breath, pain in the right half of the chest and coughing up of blood.

History: 20-year duration of varicose disease of lower extremities veins. In the last 2 weeks’ edema of the left lower limb increased, and there appeared a nagging pain in his left leg while walking and at rest, dyspnea with minimal exertion.

PhE: RR is 18 /min. Asymmetric swelling of the lower extremities (more on left), tenderness, and redness on palpation of the left shin. Increase in vocal fremitus and dullness below the angle of the right scapula, bronchophony and bronchial breathing present there as well.

Complete blood count: white blood cells 13,1x109/L, 88% neutrophils (bands - 3%), platelets 440x109/L, erythrocyte sedimentation rate 32 mm/h.

Biochemical analysis of blood: C-reactive protein is 2.9 mg /L. D-dimers: 8.53 mg / L.

Chest X-ray: Right infiltration of lung tissue, conical shape with the apex directed to the mediastinum

ECG: heart rate of 95 beats/min, the deviation to the right (RAD) syndrome of SI-QIII

Angiography: contrast defects in the right pulmonary artery Echocardiography: dilatation of the right chambers, EF 60%. Pulmonary Artery Systolic Pressure = 68 mmHg. Art. Mitral regurgitation of 1st degree and 2nd degree tricuspid failure.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 13

A male patient of 52 years complains of cough with abundant mucopurulent sputum, "a mouth full of" up to 300 ml per day, occasionally mixed with blood, dyspnea, weakness.

History: sick for 10 years with periods of exacerbation and remission. PhE: body temperature 37,4 °C. BMI 19 kg/m2. RR - 20/min. Diffuse skin cyanosis. Clubbing. Vocal fremitus is a bit increased, dullness on percussion, crackles are heard on the background of weakened vesicular breathing in the subscapular area. Heart rate is 71 beats/min, blood pressure 120/80 mmHg, Heart sounds rhythmic, accent 2 tones of the pulmonary artery.

Complete blood count: white blood cells 13,4x109/L, 76% neutrophils (bands - 4%), erythrocyte sedimentation rate =62 mm/h.

Biochemical analysis of blood: C-reactive protein = 15 mg /L, fibrinogen= 9 g / L.

Sputum analysis: Klebsiella pneumoniae 108, Staphylococcus aureus 106

Chest X-ray: pulmonary pattern is strengthened and deformed, and has cellular character

Bronchography: cylindrical bronchiectasis, ending blindly. Bronchi are close together, arranged in parallel.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 14

A 47-year-old patient complains of a cough with scant sputum, a lowgrade fever for six months, sweating, especially at night, a weight loss of 12 kg over the past 6 months.

History: The patient worked as a salesman in a second-hand bookshop. PhE: state of moderate severity. BMI 21 kg/m2. Skin and mucous membranes are clean and pale. Palpable cervical and supraclavicular lymph nodes on the left up to 8 mm, painless when palpated. RR 17 /min. The chest is not visually changed; palpation painless, resistance is not changed. Vocal fremitus is strengthened on the left overand in subclavian areas. Percussion determines tympanic sound on the left

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above the upper lobe. Auscultation reveals bronchial breathing, crackles and wheezing in the left supraand subclavian areas. Complete blood count: white blood cells 13,4x109/L, 79% neutrophils (bands - 4%), 14.7% lymphocytes, erythrocyte sedimentation rate= 38 mm / h.

Biochemical analysis of blood: C-reactive protein is 19.1 mg / L, fibrinogen 5.9 g / L.

The general analysis of sputum: Mycobacterium tuberculosis, elastic fibers, cholesterol crystals and calcium salts.

Chest X-ray: in the upper lobe of the left lung, a formed "dry" cavity with a distinct internal and less distinct outer contour is defined – a cavern.

What is (are) the leading syndrome(s)?

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What is the assumed diagnosis?

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Task 15

A male patient of 58 years, smoking 30 cigarettes per day for 40 years, complains of cough with mucopurulent sputum, shortness of breath, edema of the lower extremities, abdominal distension, fatigue, daytime sleepiness.

PhE: state of patient is of moderate severity, BMI 46 kg/m2, diffuse cyanosis, swollen neck veins, massive swelling of lower legs, ascites. RR 22 /min. Thorax is barrel-shaped, palpation is painless, resistance, and vocal fremitus are not changed. Percussion - box sound. Weakened vesicular breathing, no rales. The boundaries of the heart are extended to the right. Attenuation S1, accent S2 above the pulmonary artery, systolic murmur with a maximum at the base of the xiphoid process of the sternum. Abdominal circumference is 138 cm, dullness upon percussion of sloping areas of the abdomen. Liver: 14x12x11cm.

Total blood: red blood cells= 6,2x1012 / L, hemoglobin= 178 g/L. ECG: sinus tachycardia, heart rate - 100 beats/min, a high P in the II, III, aVF; High R in V1; deep S in V6.

Chest X-ray: shows the expansion of the pulmonary artery, a moderate increase in the borders of the heart to the right.

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