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

Task 4

40-year old male complains of weakness, dizziness, heaviness in left hypochondrium

History: Took biseptol for 2 weeks for bronchopulmonary infection PhE: icteric sclera, pale skin with iсteric colour. Spleen is enlarged and nontender.

CBC: RBC 2,9х1012/l, Hb – 80 g/l, MCV 89 fl, MCH 29 pg, WBC 4,2х109/l, Platelets 170х109/l, ESR 20 mm/h

Chemistry: total bilirubin 80 μmol/l, indirect bb 60 μmol/l, LDH 700 U/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 5.

52-year old male complains of progressive weakness, dyspnea, dizziness, frequent nasal bleedings, spontaneous development of hematomas, frequent quinsies, otitis, broncho-pulmonary infections. History: Polychemotherapy was performed 6 months ago due to lung cancer. The investigations didn`t find any signs of disease progression. PE: Pale dry skin. Body temperature 37,6°С. Alopecia. Petechias and ecchymosis. HR 120 bpm. Spleen, lymph nodes are not enlarged CBC: RBC 1,7х1012/l, Ht 22%, Hb – 48 g/l, MCV 92 fl, MCH 29 pg, WBC 1,5х109/l, platelets 50х109/l, ESR 40 mm/h

Bone marrow: hypocellular with increased adipose tissue.

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 6.

28-year old male complains of weakness, fever up to 38,5°С, dizziness, ecchymoses and nasal bleedings.

History: previously has been exposed to radiation.

PhE: Pale skin. Ulcerative and necrotic changes of tonsils. Lymph nodes, liver and spleen are not enlarged.

CBC: HB 51 g/l, RBC 1,2х1012/l, MCV 82 fl, reticulocytes 1%, WBC 1,6х109/l, bands 4%, segments 33%, lymphocytes 52%, platelets 30х109/l.

Bone marrow: hypocellular with increased adipose tissue.

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 7.

38-year old female complains of weakness, fever up to 39°С for 3 weeks, night sweats, spontaneous bruises development, bleeding gums, bone pain.

PhE: pale skin and mucous, several ecchymoses on lower limbs. Gums hyperplasia. Lymph nodes, liver and spleen are not enlarged.

CBC: Hb 62 g/l, RBC 1,7х1012/l, platelets 26х109/l, WBC 1,8х109/l, blasts 35%.

Bone marrow: blasts 63%, myelocytes 0,2%, metamyelocytes 0,1%, bands 0,2%, segments 2%.

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 8.

85-year old male complains of general weakness, dizziness, heaviness in left hypochondriac region, fever up to 39°С, loss of 8 kg within a month, nose bleed, bleeding gums, multiple haemorrhages on the skin. History: all symptoms appeared month ago. Before being sick was healthy and active (walked and swam a lot).

PhE: Pale, moist skin and mucous. Temperature 38,2°С. Multiple ecchymoses and petechias on the skin. Peripheral lymph nodes are not enlarged. Liver size is 17/8-12/3-9 cm. Splenomegaly (size on percussion 14х12 cm).

CBC: RBC 1,9х1012/l, Hb 62 g/l, MCV 96 fl, MCH 30 pg, WBC 155,5х109/l, blasts 92%, segments 2%, bands 0%, lymphocytes 5%, monocytes 1%, platelets 27х109/l, ESR 50 mm/h.

Bone marrow: blasts 72%, myelocytes 0,2%, metamyelocytes 0,1%, bands 0,2%, segments 1%.

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 9.

35-year old male complains of progressive weakness, fever up to 39°С, heaviness in left hypochondrium

History: Had tonsillitis 2 months ago.

PhE: pale skin with multiple haemorrhages. Axillar lymph nodes are slightly enlarged. Splenomegaly.

CBC: Hb 76 g/l, RBC 2,0х1012/l, MCV 87 fl, WBC 3,1х109/l, blasts 35%, myelocytes 0,5%, metamyelocytes 0,5%, bands 2%, segments 33%, platelets 48х109/l, ESR 23 mm/h.

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.

55-year old male complains of general weakness, fatigue, low-grade fever for 3 months, sweating, loss of appetite, loss of 10 kg, bone pain, heaviness in right and left hypochondrium. PhE: Сachectic. Pale dry skin and mucous, temperature is 37,6°С. Lymph nodes are not enlarged. Liver size 16/7-10-9 cm. Spleen is palpable and tender (13х11 cm).

CBC: RBC 2,8х1012/l, Hct 23%, Hb 80 g/l, MCV 92 fl, MCH 28 pg, WBC 110,1х109/l, promyelocytes 5%, myelocytes 25%, metamyelocytes 22%, segments 18%, bands 15, lymphocytes 9%, monocytes 6%, platelets 160х109/l, ESR 30 mm/h

Bone marrow: predominance of granulocytes. Cytogenetic testing detected Ph-chromosome.

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 11.

55 –year old male complains of weakness, sweating, weight loss, heaviness in left hypochondrium.

PhE: pale skin and mucous. Lymph nodes are not enlarged. Spleen is palpable and tender (13х11 cm).

CBC: Hb 110 g/l, RBC 3,3х1012/l, MCV 80 fl, platelets 342х109/l, WBC 198х109/l, basophils 5,5%, eosinophils 9%, promyelocytes 2%, myelocytes 22%, metamyelocytes 20,5%, bands 15%, segments 12%, lymphocytes 8,5%.

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 12.

37-year old male complains of high temperature with no effect of antibiotics intake, bone pain.

History: Was treated for chronic myelogenous leukemia for a year. PhE: dry pale skin. Firm infiltrates on upper and lower limbs. Pain on bone percussion.

CBC: HB 70 g/l, RBC 1,9х1012/l, platelets 90х109/l, WBC 120х109/l, blasts 35%, promyelocytes 10%, myelocytes 15%, metamyelocytes 25%, ESR 90 mm/h.

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 13.

46-year male came for planned health screening.

History: works as laboratory technician in radiology department. PhE: Solid non-tender cervical lymph nodes were detected.

CBC: WBC 55х109/l, lymphocytes 78%, absolute lymphocyte level 10х109/l, segments 22%, bands 0%, eosinophils 0%, basophils 0%. Bone marrow: 40% of the nucleated cells in the aspirate are lymphoid

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 14.

68-year old male complains of general weakness, loss of appetite PhE: Enlarged submandibular, cervical, axillar, cubital, inguinal lymph nodes are palpated. Lymph nodes are solid, non-tender, matted together.

CBC: Hb 120 g/l, RBC 4,6х1012/l, MCV 92 fl, platelets 118х109/l, WBC 80х109/l, segments 22%, bands 1%, lymphocytes 73%, absolute lympocyte level 8х109/l.

Gumprecht nuclear shadows (smudge cells) are 5:100.

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 15.

28-year old woman complains of itching periodic high-grade fever for a month, profuse night sweats, exertional dyspnea. Lost 5 kg

PhE: Dry pale skin and mucous. Excoriations on the skin. Enlarged cervical and supraclavicular lymph nodes. Spleen is enlarged and nontender (size by percussion 14х12 cm).

CBC: Hb 90 g/l, RBC 2,7х1012/l, platelets 180х109/l, WBC 9,0х109/l, ESR 80 mm/h.

Chest X-ray: expansion of mediastinum

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 16.

25-year old male complains of fever up to 38,5°С, weakness, loss of 8 kg during 3 months, itching, night sweats, enlargement of cervical and axillar lymph nodes.

PhE: Moist pale skin and mucous. Temperature is 37,8°С. Enlarged aggregated movable, solid, non-tender lymph nodes are palpated in right submandibular, anterior cervical and axillar regions. Other lymphnodes are not palpable.

CBC: RBC 3,5х1012/l, Hb 116 g/l, MCV 92 fl, MCH 28 pg, WBC 10,3х109/l, platelets 190х109/l, ESR 80 mm/h.

CT of the chest – enlarged lymph nodes in mediastinum. Lymph node biopsy: Sternberg cells are detected.

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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 ENDOCRINOLOGICAL DISEASES

Task 1.

36-year-old female complains of palpitations, nervousness, insomnia, diarrhea, heat intolerance, sweating, loss of 7 kg for 3 months, lowgrade fever (up to 37,3ºС).

PE: BMI 17,6 кг/м2. Moist hot skin. Tremor of fingers. Exophthalmos. Upper lid lag on down gaze. Temperature 37,5ºС. HR 120 bpm. Enlarged solid non-tender thyroid gland is palpated. Systolic murmur is heard over gland.

Lab: TSH 0,01 μIU/ml, free Т4 26 pmol/l, free Т3 9 pmol/l. Antibodies to TSH receptors.

Ultrasound of thyroid gland: diffuse enlargement of thyroid gland with hypoechogenic structure. Increased blood flow.

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.

70-year-old female complains of palpitations, irregular heart beat, dyspnea for a week, irritability.

History: no history of previous cardiovascular disease.

PhE: BMI 22,5 кг/м2. Arrhythmic heart sounds. HR 140 bpm. Pulse 80 bpm. BP 140/60 mmHg. Enlarged solid non-tender thyroid gland is palpated.

Lab: TSH 0,02 μIU/ml, free Т4 30 pmol/l ECG: Atrial fibrillation.

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.

52-year old female complains of insomnia, easy crying, abdominal pain, diarrhea, grittiness and diplopia, tearing.

PhE: BMI 17,2 кг/м2. Hot skin. Tremor of the fingers and head. Wide palpebral fissure, exophthalmos. Edema and hyperemia of eye-lids. HR 100 bpm. 2nd grade goitre.

Lab: TSH 0,04 μIU/ml.

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 4.

58-year-old female complains of sleepiness, dullness, memory and concentration decrease, weight gain (5 kg for 2 months), constipation, sensitivity to cold.

History: A year ago underwent subtotal resection of thyroid gland for diffuse toxic goitre. Doesn`t receive hormonal replacement therapy. According to patient`s relatives words she started to snore and to hear worse.

PhE: hoarseness. Dull puffy face. Enlarged tongue with teeth indentations. Firm edema of the legs. Dry cold skin. Thin hair. HR 48 bpm. Muffled heart sounds.

Lab: total cholesterol 8,6 mmol/l, TSH 53 μIU/ml, free Т4 3,1 pmol/l. ECG: sinus rhythm with low voltage of QRS. HR 46 bpm.

Leading Syndrome(s)

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