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

Task 3

69 year old male complains of shortness of breath quickly accrued to the extent of suffocation, worsening in horizontal position, cough with albuminoid pink sputum. Complaints appeared after emotional stress.

History: a long-term history of hypertension with episodic intake of antihypertensive therapy.

PhE: orthopnea. Acrocyanosis, moist skin. Distention of jugular veins. Bubbling breathing. RR 30/min. A large number of rales of different caliber over the surface of both lungs. The boundaries of the relative dullness of the heart are shifted to the left. Predominance of S2 in the 2nd intercostal space to the right from sternum. BP 214/122 mmHg, HR 96 beats/min.

ECG: sinus rhythm. ST segment depression in V4-V6 leads. SokolovLyon index is 42 mm.

Interpret the results of a general examination

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Interpret the results of auscultation of the lungs

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Interpret the results of auscultation of the heart

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Interpret the level of blood pressure and match it with clinical presentation

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Interpret the results of ECG

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Name the leading syndrome(s) and probable diagnosis

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Specify further investigation and principles of treatment

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Task 4

45 year old male, a smoker complains of compressing burning pain behind the sternum that appears at fast walking and climbing up 3 stairwells, radiates to the jaw, lasts for 5 minutes and stops at rest.

Family history: his mother is 67 years old, has hypertension, at the age of 50 experienced stroke.

PhE: BMI is 36 kg/m2, waist circumference is 105 cm. Yellow plaques on the eyelids. Apex beat is palpated 2 cm outwards from the left midclavicular line in the V intercostal space, reinforced, resistant, with an area of 2 cm2. The boundaries of the relative dullness of the heart are shifted to the left. Predominance of S2 in the 2nd intercostal space to the right from sternum. BP is164/92 mmHg, HR 74 beats/min.

Lab: total cholesterol 6.5 mmol/l, LDL-cholesterol 3.6 mmol/L, ECG: sinus rhythm. Left axis deviation. Sokolov-Lyon index is 37 mm.

Treadmill test: the compressive retrosternal pain occurred within 5 minutes after the beginning of the test. The pain was accompanied by 2 mm ST-segment depression in the leads I, aVL, V4-V6. The test was stopped. Pain was relieved by nitroglycerine intake. ST segment returned to the baseline 2 minutes after the end of the test.

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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Interpret the results of auscultation of heart

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Interpret the results of lab tests

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Interpret the results of ECG

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Interpret the results of treadmill test

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Leading syndromes and probable diagnosis?

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Principles of treatment?

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Task 5

51 year old female, a smoker, complains of burning retrosternal pain behind that occurs at night or early in the morning, lasts for 15-20 minutes, partially stopped by nitroglycerin intake.

PE and lab tests are normal. Treadmill test is negative.

Holter ECG monitoring: 2 mm ST-segment elevation in leads V3-V5 was registered for 10 minutes during an episode of chest pain at 4 a.m.

Name the leading syndrome(s)

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Name probable diagnosis?

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Specify further investigations

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Principles of treatment

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Task 6

68 year old male complains of pressing pain behind the sternum that occurred at rest, lasted for 40 minutes. He took 3 tablets of nitroglycerin without effect. Pain was stopped after i.v. infusion of nitrosorbide by the ambulance team.

History: smokes (40 pack/year), has a history of arterial hypertension. Describes episodes of exertional retrosternal pain lasting about 5 minutes, relieving by rest or by nitroglycerin intake. The episodes started 4 years ago.

PhE: waist circumference is 106 cm, BP 162/84 mmHg, HR 72 beats/min

ECG: sinus rhythm. 3 mm ST-segment depression in leads I, aVL, V4V6. Resolution of ST-segment was observed within 3 hours. Echocardiography: the contractility of LV is normal

Lab: troponin <0.01 ng/ml, CK-MB 0.7 ng/dL. All parameters remained within normal limits in repeated tests.

Specify the risk factors

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Name the leading syndrome(s)?

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Name probable diagnosis?

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Principles of treatment?

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Task 7

56 year old female complains of new onset of intense pressing chest pain radiating to the left arm, neck, jaw, lasting more than an hour, accompanied by a sense of of impending doom. The pain occurred while she was working in the garden. She took a tablet of nitroglycerin without effect. The pain stopped after i.v. administration of morphine. History: a smoker, with a 5 year history of type 2 diabetes mellitus PhE: waist circumference is 98 cm. BP 136/82 mmHg, HR 72 beats/min

Lab: Troponin 0,153 ng/ml, CK-MB 5,2 ng/dL

ECG: sinus rhythm. 5 mm ST-segment elevation in leads I, aVL, V1V6 and 1 mm ST-segment depression in leads II, III, aVF.

Specify the risk factors

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Name the leading syndrome(s)?

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Name probable diagnosis?

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Principles of treatment?

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Task 8

76 year old male complains of severe compressive chest pain, radiating to the left arm, left shoulder, severe weakness, sense of fear. Pain occurred at minimal exertion, lasted more than an hour, with no effect of the 3 nitroglycerin tablets intake.

PhE: severe condition, stupor, orthopnea. Cyanosis of the lips and nose, cold clammy sweat. RR 26/min. Harsh sound with multiple fine crackles on both sides of the lungs below lower angles of the blades. Muffled heart sounds with regular rhythm. BP 72/44 mmHg, HR 118 beats/min.

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Lab: Troponin 12,14 ng/ml

ECG: sinus rhythm. 7 mm ST-segment elevation in leads I, aVL, V1V5.

Echocardiography: akinesis of anterior, septal and anterolateral segments of the left ventricle. Left ventricular ejection fraction is 24%.

Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Principles of treatment?

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Task 9

79 year old female complains of pressing, burning pain behind the sternum that occurred at rest and lasted for about an hour. Three times used nitrosorbide without effect.

History: has arterial hypertension, dyslipidemia, describes symptoms of stable angina of 2nd functional class for 6 years.

ECG: sinus rhythm. 4 mm ST-segment depression and deep negative T-waves in leads I, aVL, V1-V6.

Lab: Troponin 1,8 ng/ml, CK-MB 9,0 ng/dL.

Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Task 10

32 year old female complains of shortness of breath and heart palpitations during a daily activity, intermittent fever up to 37,7°C, hemoptysis, attacks of dry cough, suffocation in a horizontal position.

History: As a child, often had sore throat, which was followed by migratory arthralgias in the knees and elbows.

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PhE: Acrocyanosis, flush on the cheeks. Slight edema of the ankles. Diastolic thrill at the apex. The boundaries of the relative dullness of the heart are the following: right - 4 cm outwards from the right edge of the sternum in the IV intercostal space, left – 1,5 cm inwards from the left midclavicular line in the V intercostal space, upper – at the level of the 3rd rib along the left parasternal line. Heart sounds are regular. Auscultation of the 1st point: loud S1, additional tone follows S2, diastolic murmur. Predominance of S2 in the 3rd point.

ECG: sinus rhythm. In the II lead P wave is bifid with the duration of 0,16 ms,

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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Interpret the results of auscultation of heart

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______________

Interpret the results of ECG

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Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Task 11

Female 23 years complains of reduced tolerance to physical exercise History: chronic tonsillitis since childhood

PhE: Apex beat is palpated 3 cm outwards from the left midclavicular line in the V intercostal space, reinforced, resistant, with an area of 3 cm2. The boundaries of the relative dullness of the heart are the following: right - 1 cm outwards from the right edge of the sternum in the IV intercostal space, left – 3 cm outwards from the left midclavicular line in the V intercostal space, upper – at the level of the

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III rib along the left parasternal line. Heart sounds are regular. S1 is quitter than S2 in the 1st point of auscultation. Systolic murmur on the apex is heard. Predominance of S2 in the 3rd point.

Interpret the results of palpation and percussion of the heart

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Interpret the results of auscultation of heart

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Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Task 12

80 year old female complains of pressing pain behind the sternum occurring at small physical exertion, radiating to the left arm, lasting for about 10 minutes, stopping at rest; dizziness.

PhE: skin is pale. Apex beat is palpated along the left axillar line in the VI intercostal space, reinforced, with an area of 4 cm2. Systolic thrill is palpated at the base of the heart. The boundaries of the relative dullness of the heart are the following: right - 1 cm outwards from the right edge of the sternum in the IV intercostal space, left – along the anterior axillar line in the VI intercostal space, upper at the level of the III rib along the left parasternal line. Heart sounds are regular. S1 is diminished at the apex, S2 is diminished in the 2nd point of auscultation. Rough rasping systolic murmur is heard in the 2nd and the 5th points. The murmur radiates to the carotid arteries. Pulsus tardus et parvus. BP is 138/78 mmHg.

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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Interpret the results of auscultation of heart

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Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Task 13

52 year old male complains of fever up to 39,5ºC, profuse night sweating during a month, shortness of breath on minimal exertion. History: 1,5 months ago had cholecystectomy because of the phlegmonous cholecystitis.

PhE: The body temperature is 38,2°C. Skin color is pale with gray and yellow ("coffee with milk" color), hot and moist. Hemorrhages on the conjunctiva, petechias on the lower extremities. Slight edema of the legs. De Musset's sign and carotid dance are observed. Apex beat is palpated 2 cm outwards from the left midclavicular line in the VI intercostal space, reinforced, with an area of 4 cm2. The boundaries of the relative dullness of the heart are the following: right - 1 cm outwards from the right edge of the sternum in the IV intercostal space, left – 3 cm outwards from the left midclavicular line in the VI intercostal space, upper – at the level of the III rib along the left parasternal line. Heart sounds are regular. Auscultation of the 2nd point: diminished S2, blowing diastolic murmur in the 2nd and the 5th points. Predominance of S2 in the 3rd point. BP is 152/38 mmHg. Traube and Duroziez signs are heard over the femoral artery. Liver Kurlov`s size is 14-13-11 sm, spleen is 13x8 cm.

Lab: RBC 3,2x1012/l, Hb 80 g/l, WBC 16,2x109/l, ESR 88 mm/h, CRP 56 mg/l.

Blood cultures: Staphylococcus aureus in 2 blood samples.

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Interpret the results of auscultation of heart

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Task 14

40 year old male complains of irregular heartbeat, palpitations, shortness of breath on slight physical exertion and in a horizontal position, swelling of the legs for 3 weeks.

History. The symptoms appeared after an influenza a month ago. PhE: orthopnea. Cyanosis of the lips. Edema of the legs. Distention of jugular veins. Vesicular breath sounds with fine crackles in lower parts of the lungs on both sides. RR 26/min. Apex beat is palpated 2 cm outwards from the left midclavicular line in the V intercostal space, with an area of 2 cm2. The boundaries of the relative dullness of the heart are the following: right – 3 cm outwards from the right edge of the sternum in the IV intercostal space, left – 2 cm outwards from the midclavicular line, upper – at the level of the II intercostal space along the left parasternal line. Heart sounds are muffled and irregular. Diminished S1 and blowing systolic murmur at the apex. Predominance of S2 in the II intercostal space to the left from the sternum. BP is 118/72 mmHg, HR 92 beats/min. Liver Kurlov`s size 12/3-9-8 cm. ECG: sinus rhythm. Frequent ventricular ectopic beats. Echocardiography: Dilation of the heart chambers. Diffuse decrease in myocardial contractility, ejection fraction is 36%.

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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Name the leading syndrome(s)?

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Formulate and justify the diagnosis?

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Specify further investigations

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Principles of treatment?

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Interpret the results of auscultation of heart

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Task 15

25 year old male complains of constant nagging, dull chest pain, radiating to both arms, neck, trapezoidal muscle. The pain gets worse during inspiration, in the supine position, at swallowing, coughing, body movements and is relieved in the sitting position with leaning forward.

History: The pain started within a week after acute respiratory viral infection.

PhE: The body temperature is 37,2°C. Superficial breathing. The boundaries of the heart are not expanded. Heart sounds are muffled, regular. Quiet rasping murmur resembling the crunch of snow is heard along the left sternal edge. The murmur gets louder after putting stethoscope closer to the chest and when the patient leans forward. The murmur is not associated with the phases of the cardiac cycle and doesn`t radiate. HR is 84 beats/min.

ECG: sinus rhythm. 3 mm ST-segment elevation with positive T waves and PR depression in all leads except aVR.

Interpret the results of a general examination

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Interpret the results of palpation and percussion of the heart

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