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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3256_Библиотеки_им_академика_М_И_Перельмана
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MINISTRY OF EDUCATION AND SCIENCE
OF THE KYRGYZ REPUBLIC
STATE EDICATIONAL INSTITUTION
OF HIGNER PROFESSIONAL EDICATION
KYRGYZ-RUSSIAN SLAVIC UNIVERSITY
named after the rst President of the Russian Federation B.N. Yeltsin
MEDICAL FACULTY
PRACTICAL HANDBOOK:
CLINICAL CASES
IN POLYCLINIC THERAPY
Approved by the Ministry of Education and Science
of the Kyrgyz Republic as a manual for students
of higher educational institutions
Bishkek 2023
UDC 616-08-039.57=111
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P 69
Reviewers:
M.B. Usubaliev, MD, Professor of Family Medicine department of KSMA
named after I.K. Akhunbaev,
G.J. Suranova, associate Professor of Kyrgyz Republik Bishkek s.
Department International r School of Medicine Establishment,
N.A. Toktogulova, Associate Professor, Head of Therapy Department No. 1
specialties “Pediatrics and dentistry”
of Kyrgyz-Russian Slavic University named after B.N. Yeltsin
Authors:
S.M. Shahnabieva,
Zh.A. Mamasaidov, I.S. Sabirov,
O.O. Karshina, Sh.Sh. Hasanova, A.V. Belinova
Recommended for publication by the Scientific Council
of Kyrgyz-Russian Slavic University named after B.N. Yeltsin
P 50 PRACTICAL HANDBOOK: CLINICAL CASES OF POLYCLINIC THER-
APY / S.M. Shahnabieva, Zh.A. Mamasaidov, I.S. Sabirov, O.O. Karshina,
Sh.Sh. Hasanova, A.V. Belinova. – Bishkek: KRSU Publishing House,
2023. – 402 p.
ISBN 978-9967-19-939-2
The textbook is devoted to the current problems of family medicine - improving
the level and quality of knowledge of doctors at the polyclinic stage of providing med-
ical and preventive care to the population. The collection of clinical cases can become
a tool for primary health care doctors in dierential diagnosis, treatment and primary
and secondary prevention, examination of working capacity, medical examination.
It is intended for medical institutions of higher education, as well as clinical
residents and students.
UDC 616-08-039.57=111
BBC 53.5
ISBN 978-9967-19-939-2 © SEIHPE KRSU, 2023
3
Contents
Abbreviations ......................................................................................4
Introduction
.........................................................................................6
Chapter 1. Pulmonology section .......................................................8
Chapter 2. Standard of answers
for the pulmonology section.............................................................22
Chapter 3. Cardiology section
......................................................... 56
Chapter 4. Standard of answers for the cardiology section
.............70
Chapter 5. Rheumatology section..................................................118
Chapter 6. Standard of answers for the rheumatology section ......135
Chapter 7. Gastroenterology section .............................................165
Chapter 8. Standard of answers
for the gastroenterology section.......................................................179
Chapter 9. Nephrology section ......................................................245
Chapter 10. Standard of answers for the nephrology section ........260
Chapter 11. Endocrinology section ...............................................324
Chapter 12. Standard of answers for the endocrinology section ...332
Chapter 13. Hematology section ..................................................357
Chapter 14. Standard of answers for the hematology section
.......367
Conclusion ......................................................................................397
Bibliography ...................................................................................398
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ABBREVIATIONS
AF – atrial brillation
AFR – Acute renal failure
AHRQ – Agency for Healthcare Research and Quality
ASA –aspirin
ATRIA – Anticoagulation and Risk Factors in Atrial Fibrillation
BRI – Bleeding Risk Index
BP – Blood pressure
BR – Breath rate
CAT – COPD assessment test
CBC – Complete blood count
CDSR – Cochrane Database of Systematic Reviews
CER – Comparative Eectiveness Review
CHADS2 – Congestive heart failure, Hypertension, Age ≥75, Di-
abetes mellitus, prior Stroke/transient ischemic attack (2 points)
CHA2DS2-VASc – Congestive heart failure/left ventricular
ejection fraction ≤ 40%, Hypertension, Age ≥75 (2 points), Diabe-
tes mellitus, prior Stroke/transient ischemic attack/thromboembolism
(2 points), Vascular disease, Age 65–74, Sex category female
CI – condence interval
COPD – Chronic obstructive pulmonary disease
CT – computed tomography
DM – Diabetes mellitus
eGFR – estimated glomerular ltration rate
ESC – European Society of Cardiology
FDA – U.S. Food and Drug Administration
GWTG – Get With The Guidelines
HAS-BLED – Hypertension, Abnormal renal/liver function,
Stroke, Bleeding history or predisposition, Labile international nor-
malized ratio, Elderly (>65 years), Drugs/alcohol concomitantly
HR – hazard ratio
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HTN – Hypertension
ICH – intracranial hemorrhage
INR – international normalized ratio
ISTH – International Society on Thrombosis and Hemostasis
ITT – intention-to-treat
ITU – Intensive therapy unit
IV – intravenous
KQ – Key Question
LAA – left atrial appendage
LMWH – low molecular weight heparin
MI – myocardial infarction
Mg – Milligrams
MRA – magnetic resonance angiography
MRI – magnetic resonance imaging
NIH – National Institutes of Health
NRI – net reclassication improvement
OR – odds ratio
PCI – percutaneous coronary intervention
RCT – randomized controlled trial
RFA – radiofrequency ablation
RR – relative risk
SE – standard error
TEE – trans esophageal echocardiography
TEP –Technical Expert Panel
TIA – transient ischemic attack
TIMI – Thrombolysis in Myocardial Infarction
TTE – transthoracic echo
TTR – time in therapeutic range
VKA – vitamin K antagonist
Wt – Weight
XRT – Radiotherapy.
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INTRODUCTION
Primary care for patients has been a top priority in health reform
in many countries around the world. To support the reform, hospital
costs were limited to increase resources at the primary health care lev-
el. However, there is still slow progress in the development of the rst
aid system, which is reected in many studies. Most patients prefer to
see a doctor at tertiary care hospitals in the population, compared to
a similar study conducted in Europe and in the United States.
In the light of the reform of the medical education of the Kyrgyz
Republic and the training of a general practitioner, the main function
of the doctor of the outpatient service is to conduct high-quality diag-
nosis and treatment of the patient. In order to make a proper diagno-
sis, a general practitioner needs knowledge of the main clinical disci-
plines: surgery, obstetrics and gynecology, pediatrics, and, of course,
internal diseases. In the work of a primary care doctor, it is important
to train students in a clinic, take patients at home and provide pre-hos-
pital care. To improve the quality of primary health care for patients,
we have developed a collection of clinical cases in polyclinic therapy
were developed.
The training manual is aimed to improve the level and quality of
knowledge of doctors at the polyclinic stage of providing medical and
preventive care to the population. The collection of tasks can become
a tool for primary health care doctors in dierential diagnosis, treat-
ment and primary and secondary prevention, examination of working
capacity and medical examination.
Answers to clinical cases will help the family doctor to guide
the patient according to modern clinical guidelines. The family doc-
tor must know the system of organization of the therapeutic service;
to know the causes, mechanisms of development, clinical manifesta-
tions, methods of diagnosis, complications, principles of treatment and
prevention of diseases of internal organs; be able to make a diagnosis
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according to modern classication; be able to dene patient manage-
ment tactics; be able to prescribe and administer treatment within
professional competence; be able to organize patient care; be able to
organize patient care; be able to carry out dispensary observation and
rehabilitation of the patient; be able to draw up medical documenta-
tion; be able to provide pre-medical care for emergency conditions in
therapy; be able to organize and carry out transportation of the patient
to a medical and preventive institution. All of the above tasks are re-
ected in the standards of answers to the clinical cases.
Timely detection and full treatment of the most common diseases
(chronic bronchitis, coronary heart disease, arterial hypertension, ear-
ly manifestations of gastroduodenitis, non-calculous cholecystitis, ar-
thritis, kidney diseases, endocrine system, etc.), medical examination,
rehabilitation measures, examination of temporary incapacity to work,
organization of hospital management depends on the knowledge and
skills of the local therapist.
The handbook reects modern views on the etiology, pathogene-
sis and classication of major diseases of the respiratory, cardiovascu-
lar, excretory, endocrine systems, which is very important for a family
doctor. The tasks also provide information on epidemiology, clinical
picture of diseases of internal organs, criteria for their diagnosis, dif-
ferential diagnosis, treatment and prevention.
The materials of the latest scientic and practical conferences and
symposiums, as well as the standards of the Ministry of Health and
Social Development of the Kyrgyz Republic, the Ministry of Health of
the Russian Federation, the World Health Organization, the recommen-
dations of the Kyrgyz and Russian Society of Cardiology and Interna-
tional Medicine experts were used in the preparation of the manual.
Thus, the “Collection of clinical cases on Polyclinic Therapy” is
devoted to the current problems of Family Medicine - the organization
of curative and preventive care for the population in outpatient condi-
tions, the modern diagnostic capabilities of the polyclinic service and
their rational use, dierential diagnosis and treatment of cardiological,
pulmonological, rheumatological, gastroenterological, nephrological,
endocrinological and hematological diseases at polyclinic level.
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Chapter 1. PULMONOLOGY SECTION
Clinical case No.1
Patient N, 47 years old, an artist, turned to the family doctor at
the polyclinic. From anamnesis: has been suering from chronic ob-
structive bronchitis for about 15 years, smokes a pack of cigarettes
a day, denies the presence of other chronic diseases. Heredity is not
burdened. Currently, the patient noticed that shortness of breath in-
creased with moderate physical exertion (accelerated walking, climb-
ing the stairs to the 2nd oor), cough with mucopurulent sputum, dif-
culty breathing, weakness, sweating when he attended a conference
in another city a week ago. Body temperature periodically rises to
subfebrile in the evening.
On objective examination. The general condition is satisfactory.
Consciousness is clear. The position is active. Satisfactory nutrition.
The skin is of normal color, clean, normal humidity. Subcutaneous fat
has a homogeneous consistency, there is no peripheral edema. Hair
and nails are not changed. The thyroid gland is not visually deter-
mined, with palpation of a soft consistency, painless. Peripheral lymph
nodes are not enlarged. The muscular system is developed satisfacto-
rily. The joints are not externally changed. The cardiovascular system.
The apical beat is located in the V intercostal space 1.5-2 cm inward
from the left mid-clavicular line. With percussion, the boundaries of
relative cardiac dullness are within normal limits. During ausculta-
tion, the heart sounds are clear, rhythm is regular, murmurs are heard.
Blood Pressure (BP) 120/70 mm Hg, Heart rate (HR) – 86 in minute
The respiratory system. On examination, normal shape of the chest.
With comparative percussion over the entire surface of the lungs,
a pulmonary sound with a boxy hue is determined, the boundaries of
the lungs are lowered by 1 rib. BR - 24 in 1 min. During auscultation
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over the lungs on both sides, hard breathing is determined with pro-
longed exhalation, wheezing. On palpation, the abdomen is soft, pain-
less. The percussive boundaries of the liver are within normal limits.
The gallbladder is not palpable, palpation is painless. Defecation and
diuresis are normal.
Complete Blood Count: RBC – 4,6х10
12
/L, Нb –150 g/L, MCH –
27 pg/cell, WBC – 6,0х10
9
/L, neutrophils bands – 2%, neutrophils
segments – 67%, lymphocytes – 20%, monocytes – 8%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 20 mm/h.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 2
Patient N, 42 years old, lawyer, turned to the family doctor at
the polyclinic. From the anamnesis: has been suering from bronchial
asthma for 7 years, of moderate severity since she changed her coun-
try of residence. In childhood she was allergic to highly allergenic
foods, in youth suered from chronic allergic rhinitis in spring and
autumn, atopic dermatitis. Currently, asthma attacks 1-2 times a day
are relieved by inhalations of fenoterol, salbutamol. She did not take
inhaled corticosteroids.
On objective examination. The general condition is satisfactory.
Consciousness is clear. The position is active. Satisfactory nutrition.
The skin is of ordinary color, clean, high humidity. Subcutaneous fat
has a homogeneous consistency, there is no peripheral edema. Hair
and nails are not changed. The thyroid gland is not visually deter-
mined, with palpation of a soft consistency, painless. Peripheral lymph
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10
nodes are not enlarged. The muscular system is developed satisfacto-
rily. The joints are not externally changed.
The cardiovascular system. The apical beat is located in the V in-
tercostal space 1.5-2 cm inward from the left mid-clavicular line. With
percussion, the boundaries of relative cardiac dullness are within nor-
mal limits. During auscultation the heart tones are clear, rhythm is
regular, no murmurs. BP 110/74 mm hg. st. HR – 88 bpm.
The respiratory system. On examination, normal shape of the
chest, symmetrical. With comparative percussion over the entire sur-
face of the lungs, a clear pulmonary sound is determined, the bound-
aries of the lungs are within normal limits. With forced exhalation
- single dry wheezing. BR - 19 in 1 min.
On palpation, the abdomen is soft, painless. The percussive
boundaries of the liver are within normal limits. The gallbladder is
not palpable, palpation in its projection is painless. Defecation and
diuresis are normal.
Blood and urine analysis – within normal ranges. ECG - without
pathology. With spirometry - FVC - 73%, Tino index - 52, FEV1
- 73%.
Gynecologist examination: uterine bromyoma 4-5 weeks in size.
Questions:
1. What is the preliminary diagnosis?
2. What additional tests would you recommend to the patient, and
what are the expected results?
3. What is the patient’s management?
4. Medical and labor expertise. Dispensary observation
Clinical case No. 3
Patient N, 24 years old, CEO specialist, went to the polyclinic
to a family doctor with complaints of fever up to 39.3°C, cough with
a small amount of viscous yellowish sputum, inspiratory shortness of
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