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

Biochemical blood tests: albumin 21g/L, total cholesterol is 3mmol/L, reduced content of B12, vitamin K, iron.

Faecal studies: The volume of faeces >500g/day, microscopically shows presence of muscle fibres (creatorrhea), neutral fat (steatorrhea) and starch (amylorrhea).

Instrumental survey: no pathology is found on FEGDS, colonoscopy, ultrasound.

Leading Syndrome(s)?

___________________________________________________

Required further examination?

___________________________________________________

Recommended treatment?

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Task 9

A 22-year old, female complains of weakness, arthralgias, subfebrile body temperatures for 2-3 months. Admitted with the occurrence of erythema nodosum on the legs. In detailed interview - often disturbed by the false desires of bowel movements (tenesmus), mainly liquid stool, sometimes mixed with blood and mucous.

PhE: body weight 54kg (lost 5kg), pale skin, and blood pressure 106/64 mmHg. Erythema nodosum on the front surface of the legs. Aphtous stomatitis. Tenderness on palpation in the left iliac region.

CBC: Haemoglobin 106g/L, white blood cells 10.2 x 109/L, ESR 45mm/hour.

Colonoscopy: multiple merging ulcerations in sigmoid colon and rectum.

Biopsy of the mucous intestine: pronounced inflammatory infiltration, ulcerative defects of the mucous membrane spreading to the submucosal layer, crypts abscesses.

Leading Syndrome(s)

__________________________________________________

Presumed diagnosis?

__________________________________________________

List the extraintestinal manifestations of the disease?

__________________________________________________

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Recommended treatment?

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Task 10

A 48-year old female complains of weakness, malaise, accompanied by the state of anxiety, a sense of lump in the throat (globus pharyngeus), spastic pain in the lower abdomen, more often during the day and the evening, constipation (defecation ≤3 times per week, stool in the form of “sheep faeces”), bloating after eating, urge to defecate, a sense of incomplete emptying of the intestine after defecation. Overweight, stable. During physical study, thorough laboratory and instrumental examination no abnormalities were found.

Presumptive diagnosis?

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Do we need a specialist consultation? What is the target?

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The recommended treatment?

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CLINICAL CASES ON LIVER DISEASE

SECTION 1

Task 1.

A 52-years old man complains of heaviness in the right hypochondriac region, general weakness.

History: is sick for 7 days, does not deny the alcohol abuse.

Physical examination: single spider veins on the front surface of the thorax, palmar hyperaemia, icteric sclera.Kurlov sizees: 13/4-10/ -9 cm, liver is dense, painless. The lower pole of the spleen is palpated.

CBC: 118 g/l haemoglobin, erythrocytes 3 6 x 1012/l, leukocytes 13 x 109/l, platelets 61×109/l

Chemistry: ALT 79 u/l, AST 110 u/l, total bilirubin 47.7 µmol/l, direct bilirubin 32.1 µmol/l, alkaline phosphatase 58 u/l, GGT 23 u/l, total protein 68 g/l albumin 38 g/l, cholinesterase 4100 u/l, prothrombin index 91.

Abdominal ultrasound: expansion of the portal vein to 14 mm, splenomegaly.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Task 2

A 30-years old man complains of yellowing of skin.

Physical examination: icteric sclera, jaundice, multiple signs of injections on his arms, liver size is 12/3-10 -9 cm, liver is dense and painless.

Chemistry: total bilirubin 59 µmol/l (elevated levels of both fractions), ALT 360 u/l, AST 280 u/l.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

The most likely origin of defeat?

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Task 3

A 27-years old female complains of fever (up to 38.5° c), yellowing of the skin, discomfort in the right hypochondrium, itching, pain in large joints.

History: duration of disease is1 week. She denies receiving any drugs during the last 3 months, as well as alcohol abuse.

Physical Examination: the skin and visible mucosa are icteric; palmar erythema; spider naevi on the face and hands; erythema nodosum (three elements) on the anterior surface of the tibia and the area of the right knee joint; palpated, enlarged, painless liver (Kurlov sizes 13/4-10 -9 cm). Spleen is not palpated.

Chemistry: AST 489 u/l, ALT 440 U/L, alkaline phosphatase 364 u/l, GGT 156 u/l, total bilirubin 123 µmol/l (elevated levels of both factions), total protein g/l 98, hypergammaglobulinemia, CRP 40 u/l CBC: ESR 60 mm/h

Serology: high titer of anti-DNA and antinuclear antibodies is present. antiHCV and HBs-antigen are negative.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Task 4.

A 46-years old male with chronic alcohol abuse complains of an episode of vomiting blood and general weakness.

Physical Examination: pronounced paleness, multiple spider naevi, palmar erythema, Dupuytren's contracture, gynaecomastia. HR=115/min, BP= 90/60 mm Hg.

CBC: haemoglobin64 g/l, erythrocytes 2 7 x 1012/l, leukocytes 4 2 x 109/l, platelets 89х109/l

Chemistry: AST 53 u/l, ALT 38 u/l, alkaline phosphatase 126 IU/l, GGT 571 u/l, bilirubin 16 µmol/l.

Serology: antiHCV antibodies, HBs-antigen are negative. Ultrasound: hepatomegaly, dilation of the portal vein to 15 mm.

Leading syndrome (s)?

__________________________________________________

The presumptive diagnosis?

______________________________________________

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What is the most likely complication in this case?

___________________________________________________

Further investigations?

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Task 5

A 24-year old male complains of nausea, heaviness in epigastric and right hypochondriac region, decreased appetite.

History: intravenous drug addict.

PhE: icteric sclera; palpated enlarged, painless liver, Kurlov sizes 12/2- 10 -9 cm.

Chemistry: AST 142 u/l, ALT 148 u/l.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Further analysis?

___________________________________________________

Task 6

A 69-year old female patient complains of general weakness, increased daytime sleepiness, itchy skin, hyperpigmentation of the skin, lipomas. PE: bronze skin, scratches; xanthelasma, icteric sclera; dense painless liver. Kurlov`s size 14/5-10-10 cm.

Chemistry: alkaline phosphatase 1159 u/l, GGT 146 u/l, AST 120 u/l, ALT 60 u/l, total bilirubin 56 μmol/l.

Serology : anti-mitochondrial antibody-positive. Hbc-Ab, HBs-Ag, HCV-Ab, HBV-DNA, HCV-RNA negative.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

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Task 7

A 30-year old female patient complains of yellowing of the skin and heaviness in the right hypochondriac region.

PhE: icteric sclera, multiple traces of injections on arms, painless enlarged liver (Kurlov sizes 13/4-9-8 cm).

Chemistry: direct bilirubin 20 µmol/l, indirect bilirubin 30 µmol/l, ALT 450 u/l, AST 320 u/l.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Further analysis?

___________________________________________________

Task 8.

A 50-year old female complains of severe itching, weakness, heaviness and discomfort in the right hypochondrium, hyperpigmentation of the skin, lipomas, dry mouth and eyes.

PhE: multiple scratches; hyperpigmentation of the skin; xanthelasma; dryness of the conjunctiva and mucous membrane of the mouth; dense, enlarged liver (Kurlov sizes 16/7-11-10 cm).

Chemistry: total bilirubin 96 mkmol/l, direct bilirubin 75 µmol/l, alkaline phosphatase 1159 u/l, GGT 146 u/l, AST 230 u/l, ALT 83 u/l.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Further analysis?

___________________________________________________

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Task 9.

A 35-year old female, nurse, complains of weakness, yellowing of the sclera and skin, subfebrile fever, heaviness in the right hypochondrium. History: about a year ago injured her arm during intravenous injection of a patient with jaundice.

PhE: yellow skin and sclera, single spider naevi, palmar erythema, Kurlov size 12/3-10-9 cm.

Chemistry: bilirubin 42 µmol/l, AST 158 u/l, ALT 185 u/l.

CBC: haemoglobin 105 g/l, erythrocytes 3 ×1012/l, leukocytes, 3,2 x 109/l, platelets 110 х109/l

Serology: HbsAg and HBV DNA are both positive.

Leading Syndrome(s)

___________________________________________________

Presumed diagnosis?

___________________________________________________

Task 10.

A 58-year old male was hospitalized with complaints of weakness, enlargement of abdomen, jaundice, itching, frequent nasal bleeding. History: long-term alcohol abuse.

PhE: yellow skin and sclera, spider naevi, palmar erythema, ascites (abdominal circumference 146 cm), oedema of the lower limbs. Chemistry: total protein 60 g/l, albumin 28 g/l, bilirubin 140 μmol/l, AST 120 u/l, ALT 130 u/l, alkaline phosphatase 356 IU/l, GGT 128 u/l. Serology: HbsAg positive.

Abdominal ultrasound: expansion of the portal vein up to 15 mm, hepatomegaly.

Gastroscopy: varicose veins of the esophagus 1 degree.

Leading Syndrome(s)

______________________________________________

Presumed diagnosis?

______________________________________________

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Task 11.

A 33-year old female complains of weakness, decreased working ability, yellowing of the skin, petechias, joint pain, low-grade temperature during the previous month, and heaviness in the right upper quadrant.

History: denies the abuse of alcohol and use of any medications. PhE: icteric sclera and skin, palmar erythema, lymphadenopathy, isolated spider naevi, enlarged thyroid gland, and Kurlov sizes 12 / 3- 10-9 cm.

Chemistry: total protein 65 g / L, increased gamma globulin up to 40%, bilirubin 240 µmol / L, AST 518 U / L, ALT of 730 U / L and alkaline phosphatase 300 U / L

CBC: ESR 50 mm / hour.

Serological analysis: HCV-antibody, HBs-antigen negative, high titer of anti DNA and antinuclear antibodies.

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

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What is the presumptive diagnosis?

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Task 12.

A 47-year-old male patient complains of fatigue, abdominal distension, lower extremity edema, heaviness in the right upper quadrant, and insomnia.

History: prolonged alcohol abuse

PhE: BMI is 19 kg /m2, icteric sclera, yellow skin, palmar erythema, spider naevi, Dupuytren's contracture, ascites (abdominal circumference is 150 cm), “caput medusae", lower limb edema, Kurlov size 13 / 04-12-11 cm.

Chemistry: total protein 52 g /L, albumin 22 g /L, bilirubin 130 µmol /L, prothrombin 55%, AST 400 U / L, ALT 318 U / L , alkaline phosphatase 450 U / L and GGT 220 U / L.

Ultrasound of the abdomen: the expansion of the portal vein up to 16 mm, hepatomegaly.

FEGDS: varicose veins of the esophagus 2 degree.

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

___________________________________________________

What is the presumptive diagnosis?

______________________________________________

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Task 13.

A 55-year old male complains of weakness, heaviness in the right upper quadrant, and insomnia.

History: daily consumption of 200-250 ml of vodka.

PhE: icteric skin and mucous membranes, hand tremor, palmar erythema, telangiectasia on the face, chest, tattoos, gynecomastia, enlarged parotid glands, Kurlov sizes 17 / 8-13-13 cm.

Chemistry: total bilirubin 122 µmol / L, direct bilirubin 54 µmol / L, AST 155 U / L, ALT 140 U / L, alkaline phosphatase, 420 U / L, GGT 580 U / L.

Serology: viral hepatitis markers are negative.

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

___________________________________________________

What is the presumptive diagnosis?

___________________________________________________

_

Task 14.

A 40-year old male complains of general weakness, nausea, vomiting with an admixture of fresh blood, abdominal distension, jaundice, dull pain in the right upper quadrant.

History: sick for 1 month: progressive weakness, yellowness of the skin, abdominal enlargement. During 5 years he took 250 ml of vodka daily and he smokes a pack a day. He denies drug abuse and usage of other medications. Never had trauma, surgery or blood transfusions. No history of inherited liver diseases. Denies history of jaundice. In recent days, he increased alcohol intake.

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

__________________________________________________

What is the presumptive diagnosis?

__________________________________________________

Task 15.

A 43-year old female, a former donor, complains of general weakness, decreased ability to work, subfebrile fever, pain in right upper quandrant, jaundice, arthralgias, myalgias, dryness of skin and mucous membranes, difficulty in swallowing, blanching and numbness of fingers especially in cold weather or after handwashing in cold water, and hemorrhagic tiny-dotted skin rashes. 2 years ago, she was

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diagnosed with chronic autoimmune hepatitis with systemic extrahepatic manifestations and autoimmune thyroiditis. She receives therapy of prednisolone and azathioprine.

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

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Formulate a diagnosis?

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Task 16.

A 52-year old male, a waiter, who drinks 150 ml of alcohol every day after work, complains of weakness, increased fatigue, heaviness in the right upper quadrant, insomnia.

History: these complaints have been troubling during the last month. PhE: BMI of 32 kg / m², the skin and mucous membranes are icteric, marked tremor of the hands, palmar erythema, telangiectasia on the face, chest, tattoos, gynecomastia, swelling of the parotid gland, and hepatomegaly - 17/8 x 13 x 13 cm.

Chemistry: AST 155 U / L, ALT 140 U / l, GGT 580 U / L, alkaline phosphatase 420 U / L, total bilirubin 122 µmol / L, direct bilirubin 54 µmol / L.

Serology: markers of viral hepatitis are negative.

Liver biopsy: signs of lymphohistiocytic infiltration, necrosis, Mallory hyaline corpuscles, and fatty element infiltration of hepatocytes.

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

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What is the presumptive diagnosis?

___________________________________________________

Task 17

A 25-year old male, former drug addict, complains of general weakness, nausea, loss of appetite, and whitening of the fingers, especially after washing in cold water.

PhE: his general condition is satisfactory; the skin is of normal color, no jaundice, there is erythema of the lower extremities, a slight increase in Kurlov size 10/1 x 9 x 9 cm. The spleen is not palpable.

Chemistry: AST 65 U / L, ALT 79 U / L, alkaline phosphatase 140 U / l, GGT 60 U / L, total bilirubin 14 µmol / L.

PCR: HCV - RNA positive.

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