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

Serology: antibodies to HCV.

Liver biopsy: signs of histiolymphocytic infiltration of hepatocytes and fatty degeneration.

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

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What is the presumptive diagnosis?

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Task 18.

A 66-year old female was admitted to hospital with a leading diagnosis from polyclinic of ischemic heart disease, congestive heart failure in both circles of circulation. She complains of weight loss, insomnia, abdominal distension, breathlessness, heaviness in the right upper quadrant and severe itching over the last year, about which she was unsuccessfully treated by a dermatologist.

Objectively: skin is dark, hyperpigmented, with traces of scratching, icteric sclera, edema. Decreased vesicular sound. Borders of the heart are not changed. Sonorous cardiac sounds, no murmurs. HR 86; BP 140/90 mmHg. Belly is greatly increased in size due to ascites. Hepatomegaly 15/6 x 14 x 13 cm. The spleen is 8 x 10 cm.

Chemistry: Bilirubin 62 mmol/L, direct bilirubin 28 mmol / L, AST 44 U / L, ALT 46 U/L, Alkaline phosphate 660 U / L, cholesterol 6.8 mmol / L, GGT (gamma glutamyl transpeptidase) 388 U / L, total protein 59 g / L.

Echocardiography: ejection fraction 55%. ECG: no pathology.

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

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What is the presumptive diagnosis?

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CLINICAL CASES OF KIDNEY DISEASE

Тask 1.

42-year old male complains of painless passage of red urine.

History: the symptoms appear periodically for 10 years after acute respiratory infections. Previous tests show slight proteinuria, microhematuria.

PhE: absence of edema, kidney punch symptom is negative on both sides. BP 130/80 mm Hg.

Urinalysis: specific gravity 1020, protein 0.165 g/l, erythrocytes 10-15 per high power field;

Nechiporenko test: leukocytes 750/ml, erythrocytes 20 000/ml. 24-h proteinuria: protein 0.3 g.

Blood chemistry: total protein 72 g/l, albumin 43 g/l, creatinine 70

μmol/l, GFRCKD-EPI 110 ml/min/1.73 m2, Ig A 7.5 g/l.

Kidney ultrasound is normal

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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Task 2.

30-year old male complains of puffy face, headache, dyspnea, decreased diuresis (350 ml/day), red-colored cloudy urine, urination is painless.

History: 2 weeks ago had tonsillitis. Has a history of chronic tonsillitis. Denies having any kidney disease and hypertension.

PhE: Pale skin, puffy face, moderate edema of lower limbs. BP 170/100 mmHg. Kidney punch symptom is negative.

Urinalysis: red cloudy urine, protein 1,5 g/l, modified erythrocytes >100 per high power field (HPF), leukocytes 5-7 per HPF, erythrocyte casts 1-2.

24-proteinuria: protein 2,5 g/d.

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Blood chemistry: total protein 72 g/l, albumin 42 g/l, creatinine 73→164 μmol/l in 2 days (GFRCKD-EPI 118→48 ml/min/1.73 m2), potassium 5.8 mmol/l, ASO 800 U.

CBC: ESR 28 mm/h.

Leading Syndrome(s)

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Presumptive diagnosis?

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Recommended treatment?

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Task 3.

64-year old female complains of edema of lower extremities, high BP. History: type 2 DM for 16 years with poor glycemic control. Arterial hypertension for 6 years. Within last year – progressive edema of lower limbs, decreased vision. 6 months ago creatinin was 110 μmol/l,

GFRCKD-EPI 46 ml/min/1.73 m2.

PE: massive edema of lower extremities, anterior abdominal wall. Dull percussion sound and absence of breath sounds below right scapula angle. BP 160/110 mmHg. Kidney region is unchanged. Kidney punch symptom is negative.

Blood chemistry: total protein 51 g/l, albumin 23 g/l, creatinine 115 μmol/l, GFRCKD-EPI 43 ml/min/1.73 m2, colesterol 8.6 mmol/l, glucose 11,2 mmol/l.

CBC: НbА1с 9%; Hb 103 g/l, MCV 82 fl, MCH 27 pg. 24-hours proteinuria: protein 9.3 g.

Urinalysis: specific gravity 1015, protein 4,6 g/l, glucose 5,8 mmol/l, leukocytes 8-10 per high power field (HPF), erythrocytes 5-7 per HPF, no bacteria.

Leading Syndrome(s)

__________________________________________________

Presumptive diagnosis?

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Recommended treatment?

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Task 4.

45-year old female complains of fever up to 38-38.50C, chills, dull pain in lumbar region after overcooling.

PhE: pain on palpation of costo-vertebral points and positive kidney punch symptom on both sides.

Urinalysis: Urine is yellow, cloudy, specific gravity is 1023, protein 0.066 g/l, leukocytes 30-40 per high power field (HPF), bacteria. Nechiporenko test: leukocytes 29750/ml, erythrocytes 250/ml.

CBC: leukocytes 12.7 x 109, bands 12%, ESR 42 mm/h.

Blood chemistry: creatinine 72 μmol/l, GFRCKD-EPI 87 ml/min/1.73 m2, CRP 32 mg/l.

Leading Syndrome(s)

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Presumptive diagnosis?

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Recommended treatment?

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Task 5.

74-year old male complains of weakness, fatigue, pruritus.

History: 20 years’ history of AH. Proteinuria onset was 6 years ago. Within last year had nocturia and above mentioned symptoms.

PhE: icteric skin with scratches, pale mucous, BP 180/110 mm Hg. Blood chemistry: total protein 66 g/l, albumin 32 g/l, creatinine 320 μmol/l, GFRCKD-EPI 15 ml/min/1.73 m2, BUN 18,6 mmol/l, potassium 6,1 mmol/l.

CBC: normochromic normocytic anemia.

Urinalysis: specific gravity 1010, protein 0.66 g/l, leukocytes 1-2 per high power field (HPF), erythrocytes 2-3 per HPF.

24-h proteinuria: protein 420 mg.

Ultrasound: decreased kidney sizes.

Leading Syndrome(s)

___________________________________________________

Presumptive diagnosis?

___________________________________________________

Recommended treatment?

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Task 6.

36-year old male complains of high BP, vision impairment, progressive edema, decreased amount of urine.

History: BP started to elevate 6 months ago. 3 months ago creatinine level was 210 μmol/l.

PhE: pronounced edema of lower extremities, abdominal wall and lumbar region. BP 240/120 mm Hg

Blood chemistry: total protein 53 g/l, albumin 20 g/l, creatinine 454 μmol/l, (GFRCKD-EPI 13 ml/min/1.73 m2).

Urinalysis: protein 4 g/l, modified erythrocytes 80-100 per high power field.

24-h proteinuria: protein 16 g.

Leading Syndrome(s)

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Presumptive diagnosis?

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Recommended treatment?

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Task 7.

Middle-aged male complains of chills, high-grade fever 38.5 – 390С, dull pain in right lumbar region.

History: several episodes of renal colic with passage of grey-black concrements.

PhE: pain on palpation of costo-vertebral points, positive kidney punch symptom on the right, pain on palpation of right hypochondrium. Urinalysis: Urine is yellow, cloudy, specific gravity is 1020, protein 0.132 g/l, leukocytes 200 per high power field (HPF), erythrocytes 3-4 per HPF, bacteria.

Nechiporenko test: leukocytes 298 000/ml, erythrocytes 2 500/ml. CBC: leukocytes 12.2 x 109/l, bands 12%, ESR 35 mm/h.

Choose necessary laboratory and instrumental tests: total protein, albumin, creatinine, eGFR, urine culture, kidney ultrasound, excretory urography, cystoscopy.

Leading Syndrome(s)

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Presumptive diagnosis?

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Recommended treatment?

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Task 8.

42-year old male describes episodes of painless macrohematuria during acute respiratory infections.

PE: BP 130/80 mm Hg.

Blood chemistry: total protein 72 g/l, albumin 43 g/l, creatinine 70

μmol/l, GFRCKD-EPI 111 ml/min/1.73 m2, Ig A 7.5 g/l CBC: ESR 11 mm/h.

Urinalysis: protein 0.165 g/l, Nechiporenko test: erythrocytes 20 000/ml.

Kidney biopsy: membranoproliferative glomerulonephritis with IgA deposits.

Leading Syndrome(s)

__________________________________________________

Presumptive diagnosis?

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Recommended treatment?

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Task 9.

27-year old female complains of first onset of painful frequent urination and red urine. Symptoms appeared after overcooling.

PE: no edema, BP 120/77 mm Hg Palpation of costo-vertebral points is painless, kidney punch symptom is negative on both sides. Urinalysis: red-colored urine, protein 0.66 g/l, unchanged erythrocytes >100 per high power field (HPF), leukocytes 25-30 per HPF, bacteria. CBC: normal.

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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Task 10.

30-year old male complains of headache, high BP (up to 210/150 mm Hg).

History: The symptoms appeared 2 days ago. 2 weeks ago had acute pharyngitis. Denies having any chronic disease.

PE: puffy face, mild edema of the shins, lumbar region is unchanged, kidney punch symptom is negative on both sides, BP 190/110 mm Hg. Urinalysis: specific gravity 1020, protein 0.5 g/l, erythrocytes 15-20 per high power field (HPF); erythrocyte casts 20-30 per HPF.

Nechiporenko test: leukocytes 6500/ml, erythrocytes 5100/ml 24-hours proteinuria: protein 0.7 g.

Blood chemistry: total protein 72 g/l, albumin 43 g/l, creatinine 70

μmol/l, GFRCKD-EPI 100 ml/min/1.73 m2, CRP 38 mg/l, ASLO 550 IU/ml.

Ultrasound: normal.

Kidney biopsy: diffuse proliferative glomerulonephritis.

Leading Syndrome(s)

___________________________________________________

Presumptive diagnosis?

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Recommended treatment?

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Task 11.

37-year old female complains of fever up to 38,9 С, chills, pain in right lumbar region.

History: The symptoms appeared 3 days ago after overcooling.

PhE: Kidney punch symptom is positive in right lumbar region. BP 120/76 mm Hg temperature 38,7 С.

CBC: leukocytes 15 x 109/l, bands 18%, ESR 100 mm/h

Blood chemistry: CRP 57 mg/l, creatinine 74 μmol/l, GFRCKD-EPI 95 ml/min/1.73 m2.

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Urinalysis: leukocytes cover the whole high power field, a lot of bacteria.

Ultrasound: normal.

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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CLINICAL CASES ON HEMATOLOGICAL DISEASES

Task 1. A 47-year old female complains of fatigue, weakness, dizziness, tinnitus, desire for unusual smells, brittle nails, hair loss. History: irregular excessive menses.

PE: pale and dry skin and mucous membranes, angular fissuras, lines on the nails, koilonychias, HR 110/min.

Lab: RBC 2,1х1012/l, Hb 74 g/l, HCT 30%, MCV 72 fl, MCH 23 pg, anysocytosis, poikilocytosis.

Chemistry: serum iron 3,2 μmol /l, ferritin 6 ng/ml, total iron binding capacity of serum 80 μmol/l.

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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Task 2.

A 76-year old female complains of progressive weakness, paresthesias in fingertips, burning tongue, impaired gait, edema of lower limbs, dyspnea at mild exertion.

PhE: Pale skin with icteric colour. Edema of shins. Systolic murmur on the apex of heart. HR 92/bpm. Liver size 12/2-11/3-10/3 cm. Spleen and lymph nodes are not enlarged.

CBC: Hb 52 g/l RBC 1,2х1012/l, MCV 127 fl, MCH 36 pg, WBC 3,0х109/l, platelets 124х109/l.

Chemistry: total bilirubin 56 μmol/l, indirect bilirubin 42 μmol/l LDH

482U/l

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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Task 3.

A 72-year old female complains of progressive weakness, dizziness, tinnitus, dyspnea and palpitations at mild exertion, burning in tongue, numbness of the feet, shaky walk.

PE: skin and mucous membranes are pale with icteric colour. Smooth tongue without papillae. Edema of lower extremities. HR 100 bpm. Systolic murmur at the apex of heart. Liver size 12/3-10/2-8/1 cm. Spleen is palpable (size 12х10 cm). Decreased sensitivity of the fingers, shaky walk.

CBC: RBC 1,8х1012/l, HB 57 g/l, HCT 27%, MCV 116 fl, MCH 36 pg, WBC 3,2х109/l, platelets 100х109/l, ESR 30 mm/h, Jolly bodies, Cabbot rings, poikilocytosis

Chemistry: total bilirubin 56 μmol/l, indirect bilirubin 43 μmol/l, LDH 500 U/l

Bone marrow: megaloblastic EGDS: atrophy of the mucous layer

Leading Syndrome(s)

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Further investigations

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Presumptive diagnosis?

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Recommended treatment?

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