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

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 16

71 year old male complains of increasing dyspnea at rest, edema of feet and legs, heaviness in the right hypochondriac region.

History: 5 years ago has experienced myocardial infarction. Since that time has constant atrial fibrillation.

PE: Orthopnea. Pale skin. Cyanosis of the lips, nose, nails. Symmetrical edema of the legs, thighs, anterior abdominal wall. Distention of jugular veins. Harsh breath sounds with multiple fine crackles below the angles of the blades are heard. RR is 28/min. 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 in the VI intercostal space, upper at the level of the II intercostal space along the left parasternal line. Heart sounds are muffled and irregular. S1 is diminished at the apex. Predominance of S2 in the II intercostal space to the right from the sternum HR is 116 beats/min, pulse is 88 beats/min. BP is 114/72 mmHg Enlargement of the abdomen with dull percussion sound in the lateral parts of the abdomen. Liver Kurlov`s size is 14/5-9-8 cm. Liver edge is rounded and tender.

ECG: atrial fibrillation. Pathological Q-wave in the leads I, aVL, V3V4.

Echocardiography: Dilation of the heart chambers. Diffuse decrease in myocardial contractility, akinesia of the apical and septal segments. Ejection fraction is 32%.

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Interpret the results of a general examination

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Interpret the results of auscultation of heart

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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?

___________________________________________________

Specify further investigations

___________________________________________________

Principles of treatment?

___________________________________________________

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CLINICAL CASES ON GASTROENTEROLOGY

SECTION 1

Task 1.

A 34-year-old male with abdominal obesity complains of burning behind the sternum and acid eructation. Symptoms appear mainly after eating spicy fried food, increase in a horizontal position. The patient denies pain and difficulty in swallowing and weight loss.

Leading syndrome(s)?

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The presumptive diagnosis?

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Necessary examination?

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Task 2.

A 42-year female with a long history of gastric ulcer complains of loss of appetite, a feeling of fullness in epigastric region, episodes of vomiting food taken the day before. On physical examination: mild pain on palpation in epigastric region. Downward displacement of large curvature of the stomach. Abdominal radiography with barium revealed increased size of the stomach.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

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Task 3.

A 40-year-old man, heavy smoker (smoking index is 120) with the first complaint of pain in the epigastric region after 1.5 – 2 hours after eating and at night without irradiation, pain is relieved after meals or taking antacids. The condition has been deteriorating over the past 2 weeks. Body weight is stable. Didn`t not take any NSAIDs.

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Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

Necessary examination?

___________________________________________________

Task 4.

А 56-year-old male with a long history of stomach ulcers complains of constant pain in the epigastric region, loss of appetite, aversion to meat, nausea, weight loss of up to 11 kg for 2 months.

PhE: significant paleness, cachexia, enlarged lymph nodes in the right supraclavicular region on palpation.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

Necessary examination?

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Task 5.

A 22-year old male, student, smoker, complains of moderate pain in the epigastric region, nausea, acidic belching, associated with consumption of fast food and stressful situations. On FEGDS hyperemic gastric mucosa in pyloric antrum is found, without erosions.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

Necessary examination?

___________________________________________________

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Task 6.

A 53-year old male patient, alcohol abused, was urgently admitted with complaints of a one-time vomiting of unchanged blood. PhE: palmar erythema, jaundice, ascites, "caput medusa", swelling of the feet and legs, hypotension, tachycardia, hepatomegaly.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

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Necessary examination?

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Task 7.

A 50-year old male patient complains of pain in the umbilical region, bloating, edema, large amounts of shiny feces daily, badly washed out from the walls of the toilets. Patient underwent resection of small intestine 6 months ago for cancer.

Leading syndrome(s)?

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The presumptive diagnosis?

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Task 8.

A 32-year-old female patient complains of abdominal spastic pain since the age of 17, pain decreases or disappears after defecation. She also notes flatulence, alternation of constipation and diarrhea after taking the relaxants. No weight loss noted and no signs of gastrointestinal bleeding. No pathology is revealed in laboratory and instrumental investigations.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

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Task 9.

A 30-year old female complains of spastic abdominal pain, frequent liquid stools, blood in the feces, loss of appetite, decrease in body weight of 8 kg in 6 months, fever up to 37.5°C, arthralgias.

PhE: erythema nodosum on legs. Colonoscopy revealed portions of merging ulcerations throughout the colon, contact bleeding and strictures.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

Necessary examination?

___________________________________________________

Task 10.

A 16-year-old male complains of pain in the right iliac region, frequent (up to 8 times) loose stools, fever up to 38°C. He was urgently admitted to hospital with suspected appendicitis. Physical examination: conjunctivitis, aphthous stomatitis, soft abdomen, Blumberg sign is

Leading syndrome(s)?

______________________________________________

The presumptive diagnosis?

______________________________________________

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SECTION 2

Task 1.

A 35-year-old male complains of heartburn, acid eructation, retrosternal pain, early satiation, paroxysmal cough for 6 months and episodes of suffocation. Eructation is enhanced after eating or in the horizontal position.

PhE: Tongue is covered with white coat. Laboratory test: No pathologies detected.

FEGDS: distal esophagitis, cardiac sphincter insufficiency. No signs of respiratory and cardiovascular system diseases.

Leading syndrome(s)?

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The presumptive diagnosis?

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Recommended treatment?

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Task 2A 45-year-old male, smoker, with a 5 year history of gastric ulcer and frequent exacerbations, without recieving systemic therapy, complains of foul-smelled eructation, nausea after eating ending in abundant fountain like vomiting that brings relief. Vomit has alkaline reaction, contains pieces of undigested food eaten the day before. It is noted the patient has sitophobia (fear of eating food)

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

___________________________________________________

Necessary examination?

___________________________________________________

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Task 3.

A 42-year male complains of coffee ground vomiting.

History: He felt sick for a few years: epigastric pain persisted 30-40 minutes after eating, as well as heartburn and belching mainly in autumn and spring and after errors in diet. He never visited a doctor before. The deterioration started yesterday after eating spicy and salty food.

PhE: Tenderness on palpation in the epigastric region. Complete blood count: haemoglobin 105 g/L.

FEGDS : ulcerative gastric mucosa defect (5mm x 10mm) in the antrum coated with fibrin.

Leading syndrome(s)?

___________________________________________________

The presumptive diagnosis?

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What are the complications?

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Name of the bacteria that is the common cause of the development of stomach ulcers?

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The recommended treatment?

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Task 4.

A 46-year old male entered the emergency room complaining of acute knife-like epigastric pain, not allowing straightening, single vomiting that brought no relief.

History: Prolonged smoking (25 years- 1 pack/day), alcohol abuse. During the last 3 days he experienced bothersome and nagging hunger pains, nausea, heartburn, acid regurgitation, which was caused by the intake of aspirin and alcohol.

PhE: serious condition, forced knee-elbow position, earthy and dry skin and mucous membranes, tongue is dry and coated. The stomach does not participate in breathing, symmetrical, retracted sharply and tense, muscle strain, positive symptom of Shotkin-Blumberg, the disappearance of hepatic dullness on percussion.

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What kind of disease should be suspected?

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What complications developped in the patient?

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Тask 5

A 35-year old male complains of heartburn, acid regurgitation, recurrent night and hunger epigastric pain relieved by eating and constipation.

History: Prolonged smoking (15 years), systematically takes Diclofenac (NSAID) for post-traumatic osteoarthritis of the lumbar spinal segments.

PhE: marked local tension of the abdominal wall and tenderness in the pyloric region.

FEGDS: Edema and hyperemia of the gastric antrum. Gastric pH monitoring : 1.9.

Histological examination of biopsy specimens of gastric mucosa: H. pylori.

Urease test: Positive.

Leading Symptom(s)

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Presumptive diagnosis, and its cause?

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Recommended treatment?

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Task 6.

A 72 year old female complains of a feeling of heaviness, fullness, dull pain in the epigastrium, bad taste in the mouth, loss of appetite, nausea, gaseous eructation, unstable stool.

Anemnesis: long history of autoimmune thyroiditis.

Objectively: Skin and visible mucous membranes are pale, lacquered tongue with atrophied papillae, diffuse tension of the anterior abdominal wall and epigastric pain.

FEGDS: Paleness, smoothness, and thinning of the mucous membrane in the gastric corpus and fundus with visible blood vessels.

Gastric pH monitoring: 6.7.

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Histological examination of biopsy specimens of gastric mucosa: atrophy of the epithelium. Detected antibodies to parietal cells of the stomach and intrinsic factor.

Leading Syndrome(s)?

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Presumptive diagnosis, and reasons thereof?

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Recommended treatment?

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Task 7

A 65-year old male complains of epigastric pain, poor appetite, weight loss of 9 kg’s in the last 3 months.

History: For 15 years peptic ulcer with frequent exacerbations (1-2 times a year). Patient`s father at the age of 50 years had surgery for stomach cancer.

PhE: Pale mucous membranes and skin, BMI 17kg/m2. Supraclavicular nodes are palpable on the left; palpable mass in the epigastric region. CBC: Total haemoglobin 90g/L. ESR 60mm/ hr.

FEGDS: nodular mass with contact bleeding, up to 6cm in diameter. Ultrasonography of the abdomen: Multiple formations in the liver. Biopsy: Highly differentiated adenocarcinoma.

Leading Syndrome(s)?

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Presumptive diagnosis and reasons?

_________________________________________________

Recommended treatment?

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Task 8

A 50-year old male 3 years ago underwent resection of the stomach with a part of the small intestine due to stomach ulcers. Complains of weakness, diarrhoea, abdominal pain, edema of the lower limbs, a sense of numbness in the lower extremities.

PE: Glossitis, haemorrhage on whole body surface, swelling of lower limbs.

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