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Файл:Frailty syndrome clinic, diagnosis, treatment. Study aid
.pdf
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little effect. From the anamnesis: retired (previously worked as a teacher),
denies occupational hazards. Past surgeries: hysterectomy at 44 (for uterine
fibroids), surgical menopause. On examination: the condition is satisfactory.
Skin of physiological color. Height 160 cm, weight 52 kg, BMI 20.3 kg/m2.
When examining the musculoskeletal system, thoracic kyphosis was
enhanced, lumbar lordosis was emphasized. Painful palpation of the spinous
processes in the lumbar region. Vesicular breathing in the lungs, no
wheezing, respiratory rate 16 per minute. Heart sounds are muffled, the
rhythm is correct, heart rate is 64 per minute, blood pressure is 125/80 mm
Hg. The tongue is not coated, wet. The abdomen is soft, painless on
palpation in all departments. The size of the liver is 9(0)×8×7 cm. The spleen
is not enlarged. Tapping on the lumbar region is painless, there is no dysuria.
The chair is designed 1 time per day, without pathological impurities.
Complete blood count: erythrocytes — 4.5 × 1012/l, hemoglobin —
130 g/l, leukocytes — 7.8 × 1012/l, basophils — 0 %, eosinophils — 1 %,
segmented neutrophils — 73 %, lymphocytes — 18 %, monocytes — 8 %,
platelets — 267×109/l, ESR — 14 mm/hour. Urinalysis: pH — 6.8, specific
gravity — 1,018, protein and sugar — negative, leukocytes — 2–3 in the
field of view. 62 Biochemical blood test: total protein — 74 g/l, alkaline
phosphatase — 140 IU/l, AST — 16 IU/l, ALT — 22 IU/l, glucose —
4.5 mmol/l, creatinine — 75 µmol/l.
On the radiograph of the lumbosacral spine — anterior wedge-shaped
deformity L3 and L4.
Questions:
1. Suggest the most likely diagnosis.
2. Justify your diagnosis.
3. Draw up and justify a plan for an additional examination of the
patient.
4. Determine the plan for managing the patient using pharmacological
and non-pharmacological methods (indicating the doses of the drugs used).
5. The patient returned for a consultation after 2 years. According to
densitometry, T-score in the lumbar spine was –3.0 (at the beginning of
treatment), –3.4 (after 1.5 years); in the hip, T-scores were –2.2 and –2.5,
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respectively. In addition, 5 months ago, the patient had a low-energy
fracture of the left radius. What is your next treatment strategy? Justify your
choice.
Variant 3
1. Basic functional activities include:
a) Dressing
b) Climb up the stairs
c) Taking a bath
d) Wash
2. Instrumental functional activity includes:
a) Financial control
b) Personal hygiene
c) Phone use
d) Cooking food
3. Comprehensive geriatric assessment during dispensary observation
of patients is carried out:
a) 1 time in 2 years
b) Every week
c) Every month
d) At least once a year
4. Correction of vitamin D deficiency reduces the risk of falls and
fractures by:
a) 10–15 %
b) 35–50 %
c) 35–72 %
d) 50–90 %
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5. The most significant signs of senile asthenia are:
a) dementia
b) Urinary incontinence
c) Falls
d) Unintentional weight loss of 4.5 kg
6. The initial dose of quetiapine for behavioral disorders is:
a) 10 mg/day
b) 4 mg/day
c) 6.25 mg/day
d) 7.25 mg/day
7. The initial dose of memantine is:
a) 10 mg/day
b) 20 mg/day
c) 25 mg/day
d) 5 mg/day
8. Shoes are considered incorrectly trimmed:
a) without backs
b) heel height exceeds 2.5 cm
c) heel height exceeds 4.5 cm
d) with a heel that is compressed by more than 35 %;
e). with a heel that is more than 45 % compressed
9. The optimal intake of high quality, easily digestible protein per meal is:
a) 10–20 grams
b) 25–30 grams
c) 60–80 grams
d) 75–90 grams
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10. For patients with frailty syndrome, in order to treat and prevent
sarcopenia, it is recommended to increase protein intake to:
a) 0.9–1.5 g/kg of body weight per day
b) 1.0–1.5 g/kg of body weight per day
c) 1.0–3.5 g/kg of body weight per day
d) 1.5–2.5g/kg of body weight per day
ANSWERS: 1a, b, c; 2a, c, d; 3d; 4 с; 5a, c, d; 6с; 7d; 8а, с, е; 9b; 10b
Case 1:
Patient K., 83 years old, called the local doctor to her house.
Complaints of general weakness, weight loss by 5 kg over the past 5 years,
fatigue, difficulty moving around the house, bad mood. All these complaints
appeared about 6 years and are gradually increasing. 6 months ago she fell
at home, there were no injuries. Afraid to go outside. Objectively: the
general condition is satisfactory. Weight 58 kg, height 163 cm. No edema.
In the lungs, vesicular breathing, no wheezing. Heart sounds are weakened,
the rhythm is correct. Heart rate = 64 bpm, BP = 130/70 mm Hg. The
abdomen is soft and painless. The liver and spleen are not enlarged. The
stool is prone to constipation. There is no dysuria.
Questions:
1. What syndrome does this patient have?
2. What recommendations should be given?
Case 2:
Patient P., 70 years old, watchman, came to the dispensary
examination, no complaints. Since the age of 50 he has been suffering from
hypertension, 2 years ago he suffered a myocardial infarction. He regularly
takes bisoprolol 2.5 mg/day, losartan 50 mg/day, cardiomagnyl 75 mg/day.
Objectively: there are no edema. In the lungs, vesicular breathing, no
wheezing. Heart sounds are weakened, 2 extrasystoles in 10 minutes. Heart
rate = 72 bpm, BP = 140/70 mm Hg. The abdomen is soft and painless.
Liver — on the edge of the costal arch.
115
Questions:
1. Formulate and justify the diagnosis.
2. What examination should be ordered?
3. What mandatory group of drugs is the patient not taking?
Case 3:
Patient K., 69 years old, has been suffering from hypertension for
10 years. Irregularly takes hypothiazide and lisinopril. He was admitted with
a deterioration in health due to psycho-emotional stress: complaints of
headache in the occipital region, nausea. He has been smoking a pack of
cigarettes a day for 20 years. Objectively: BMI 26.0 kg/m2, waist
circumference — 97 cm. No edema. In the lungs, vesicular breathing, no
wheezing. The boundaries of relative cardiac dullness are extended to the
left by 1 cm. The heart sounds are weakened, the rhythm is correct. The
pulse is symmetrical, 64 beats/min. BP 180/100 mmHg Art. The abdomen
is soft, b/b. Liver — on the edge of the costal arch. Murmurs on the
peripheral arteries are not auscultated. Additional survey results.
Biochemical blood test: potassium — 4.5 mmol/l, glucose — 5.4 mmol/l,
creatinine — 99 μmol/l (GFR (EPI) = 70 ml/min), uric acid 544 μmol/l, total
cholesterol — 4.9 mmol/l, LDL cholesterol — 2.8 mmol/l, TG —
1.41 mmol/l. Albumin in daily urine — 200 mg/day. ECG shows signs of
LV hypertrophy. Plain chest x-ray — displacement of the borders of the
heart to the left. EchoCG: LV hypertrophy. Ultrasound of the kidneys
without pathology. Duplex scanning of the carotid arteries: intima-media
thickness 1.2 mm.
Questions:
1. Formulate and justify the diagnosis.
Case 4:
A 72-year-old man came for an examination, previously seen by
another doctor. She suffers from arterial hypertension, for which she
receives indapamide 2.5 mg daily. He also takes a low-dose aspirin from
time to time, as he saw the advertisement and thought it would be good for
116
him. 11 History of life without features, the presence of other chronic
diseases denies. The patient does not smoke, occasionally consumes
alcoholic beverages and does not exercise. My father died at the age of
60 from a myocardial infarction, my mother died at the age of 72 from a
malignant neoplasm, there are two younger sisters, both of whom do not
suffer from chronic diseases. On physical examination, height 170 cm, body
weight 92 kg, waist circumference 106 cm. Heart rate — 75 beats per
minute, blood pressure — 130/80 mm Hg. On organs and systems without
deviations from the norm. In laboratory analyzes of the lipid spectrum: total
cholesterol 6.23 mmol/l, high-density lipoprotein cholesterol (HDL)
1.2 mmol/l, low-density lipoprotein cholesterol 4.03 mmol/l, triglycerides
1.56 mmol/l.
Questions:
1. Formulate and justify the clinical diagnosis.
2. What additional laboratory tests should be performed on this
patient?
Variant 4
1. According to the screening questionnaire “Age is not a hindrance”,
patients are sent to the geriatric office with the result:
a) ≥ 3 points
b) ≥ 4 points
c) ≥ 5 points
d) ≥ 6 points
2. Old age according to the 2012 WHO age group classification is:
a) 55–74 years old
b) 60–74 years old
c) 75–80 years
d) 80–85 years old
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3. When detecting depression, it is preferable:
a) neuroleptics
b) selective serotonin reuptake inhibitors
c) tranquilizers
d) tricyclic antidepressants
4. For warfarin treatment, the target values for the international
normalized ratio are:
a) 1.0–3.0
b) 2.0–3.0
c) 2.0–5.0
d) 2.0–7.0
5. In the treatment of depression, the initial dose of Escitalopram is:
a) 10 mg/day
b) 15 mg/day
c) 20 mg/day
d) 5 mg/day
6. When prescribing antihypertensive therapy, the following level of
systolic pressure is recommended:
a) 120-130 mmrtst
b) 140-150 mmrtst
c) 140-160 mmrtst
d) 160-170 mmrtst
7. In the presence of aggressiveness in patients with senile asthenia, it
is recommended to use:
a) antidepressants
b) Atypical antipsychotics
c) Nootropic drugs
d) Tranquilizers
118
8. When conducting a comprehensive geriatric assessment of patients
with senile asthenia, it is recommended to assess the 10-year risk of
osteoporotic fractures using an instrument:
a) FRAX
b) STOP/START
c) Morse Fall Rating Scales
d) Empirical Risk Scale
9. In severe chronic pain syndrome, the dose of tramadol is:
a) 100–200 mg
b) 25–50 mg
c) 5–10 mg
d) 50–100 mg
10. Carrying out a complex of non-drug measures for the prevention
of delirium has a level of persuasiveness of recommendations:
a) BUT
b) AT
c) FROM
d) D
ANSWERS: 1c, 2b, 3b, 4b, 5d, 6b, 7b, 8 a, 9d, 10b
Case 1:
A man, 68 years old, on 04/18/2016 called the local doctor to the
house. Complaints of headache, dizziness, flies before the eyes, shortness of
breath when walking (after stress in the family). Anamnesis: From the age
of 50 he suffers from arterial hypertension with a maximum increase in
blood pressure numbers up to 210/110 mm Hg. Art, good health at blood
pressure 120/70 mm Hg. Art. He took Enalapril 10 mg/day irregularly.
3 months ago, he suffered an acute lower ST-segment elevation myocardial
infarction, coronary angiography was performed — 90 % stenosis of the
right coronary artery was detected, LAD stenosis 35 %, OS 30 %, in
119
connection with which transballoon angioplasty and stenting of the RCA
with a drug-eluting stent were performed. He regularly took Cardiomagnyl
75 mg/day, Clopidogrel 75 mg/day, Atorvastotin 40 mg/day, Carvedilol
12.5 mg/day, Perindopril 10 mg/day. Bad habits: smoking for 20 years,
10 cigarettes Objectively: moderate condition. The skin is clean, hyperemic.
There are no edema. In a horizontal position, increased shortness of breath.
NPV 22 per minute. Vesicular breathing in the lungs, fine bubbling wet rales
in the lower sections. Heart sounds are muffled, rhythmic. Heart rate —
88 beats. in min., BP — 190/100 mm Hg. The abdomen is soft, painless on
palpation in all departments. The liver and spleen are not enlarged. There is
no dysuria. The symptom of tapping in the lumbar region is negative.
Questions:
1. Formulate and justify the diagnosis.
2. Tactics of the local doctor.
3. Compose and justify a plan for an additional examination of the
patient in the hospital
4. Relief of hypertensive crisis. 5. Management of patients after
discharge from the hospital
Case 2:
Patient F., 78 years old, called the local doctor to the house with
complaints of palpitations, interruptions in the work of the heart, which are
accompanied by weakness, shortness of breath. Attacks of arrhythmia began
to disturb the last six months, lasting several minutes, they pass on their own
with a change in body position. From the anamnesis it is known that for the
past few years memory has begun to decline, rarely notes an increase in
blood pressure to 160/90 mm Hg. Art. Past diseases: duodenal ulcer, focal
pneumonia. At present, he is retired and worked as a teacher at a university.
Has no bad habits. Objectively: general condition of moderate severity. The
physique is correct, height — 168 cm, weight — 70 kg. Swelling of the feet
and legs. Noticeable pulsation of the neck veins. BH — 22 per minute. On
percussion, the sound is clear, pulmonary, the boundaries of the lungs are
within the normal range. On auscultation, breathing is hard, no wheezing.
120
The boundaries of relative cardiac dullness: right — the right edge of the
sternum, left — 1 cm inside from the left midclavicular line, top — the upper
edge of the III rib. On auscultation, the heart sounds are muffled,
arrhythmic. Heart rate — 112 beats/min. BP — 130/80 mm Hg. Art. The
abdomen is soft, painless in all departments. The liver is not palpable, the
dimensions according to Kurlov are 9×8×7 cm. The results of the
examination: a general analysis of blood and urine without pathology. ECG:
P waves are absent in all leads. Between the QRS complexes are small
waves “f”, the frequency of the ventricles is 110–150 per minute.
Questions:
1. What is the rhythm disturbance in the patient?
2. With what supraventricular arrhythmias should a differential
diagnosis be made?
3. What additional methods of examination will you prescribe to the
patient? Justify your answer.
4. Based on what parameters is the risk of stroke and systemic
thromboembolism estimated in this patient? Is it necessary to prescribe
anticoagulants in this patient?
Case 3:
A 72-year-old man was hospitalized at a cardiological dispensary from
09/01/2016 to 09/16/2016 due to anterior Q-forming myocardial infarction
from 09/01/2016. left shoulder blade, shortness of breath after a stressful
situation. From the anamnesis it is known that in the last 2 years, blood
pressure has periodically increased to a maximum of 160/90 mm Hg. He did
not receive constant drug therapy, episodically took captopril 25 mg. During
exercise, periodically there was discomfort in the region of the heart,
shortness of breath. He did not seek medical help. Smoked ½ pack of
cigarettes a day for over 30 years. Family history: Father died of myocardial
infarction at age 60. 09/01/2016 coronary angiography was performed,
occlusion of the anterior interventricular artery was detected, PTCA and
endoprosthesis replacement of the anterior interventricular artery were
performed. Biochemical blood test: total cholesterol — 6.36 mmol/l,
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