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1 group of disability is dened in a severe form of the disease
with pronounced hypotension, adynamia.
2 group of disability is determined with signicantly pronounced
disabilities leading to social maladjustment due to the same reasons
as in the rst group, but while maintaining the ability to self-service,
with sharply and signicantly pronounced endocrine disorders or the
development of visceral, other disorders.
3 group disability is determined in the presence of moderate or
mild endocrine disorders that restrict life activity and reduce the pos-
sibilities of social adaptation due to pronounced diculty in learning,
communication, movement, as well as labor activity (reduced quali-
cations or volume of work, diculty in performing professional work
due to anatomical defects).
Dispanserisation. Patients with acromegaly are subject to medical
examination for life. They are examined by an endocrinologist, neu-
ropathologist, ophthalmologist 4 times a year. 2 times a year, the skull
is radiographed, the content of somatotropin and glucose in the blood
is determined 4 times a year. If necessary, treatment with parlodel,
symptomatic agents, continues. Favorable prognosis with regular ad-
ministration of thyroid hormones, with refusal of it - the development
of CHD, heart failure, hydropericardium, cognitive impairment, hy-
pothyroid coma. Over time, evaluate CBC, glandular complex (as-
sessment of anemia correction), TSH, free T4 during therapy after
a month, while normalizing TSH - rst 1 times every 6 months, then
1 times a year.
Clinical case No. 9
1. What is the preliminary diagnosis?
Cushing’s syndrome.
2. What additional tests would you recommend to the patient,
and what are the expected results?
1. Group of screening tests nding out the volume of daily ex-
traction of cortisol in the urine; small dexamethasone test: double
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determination of the level of cortisol in the blood (before and after
taking dexamethasone). If the indicator rises or remains the same, this
may serve as a conrmation of Cushing’s syndrome.; large dexameth-
asone test: it diers from the small one only in the dosage of the drug.
2. Instrumental research an X-ray of the spine will reveal a pos-
sible compression fracture;
MRI or CT of the adrenal glands.
3. Laboratory tests and possible signs of Cushing’s syndrome.
y General blood analysis: erythrocytosis (increase in the level of red
blood cells) and absolute lymphopenia.
y Biochemical blood test: hyperglycemia (increase in serum glucose
concentration), hypokalemia (decrease in potassium levels),
hypernatremia (increased sodium content); biochemical analysis of
urine: an increase in the concentration of potassium and calcium;
analysis for thyroid-stimulating hormone (a decrease in its level is
100% a sign of Cushing’s Syndrome); analysis for cortisol (with
Cushing’s syndrome, the indicator is increased).
y Blood test for HbA1c (glycosylated hemoglobin): with
Cushing’s syndrome, an increase in concentration is observed.
y Blood glucose test: the concentration of glucose with
Cushing’s syndrome can be increased;
y Blood test for osteocalcin (with Cushing’s syndrome, the level of
this natural marker of osteoporosis is lowered).
3. What is the patient’s management?
1. Surgical methods.
Selective transsphenoidal adenomectomy (removal of a pituitary
tumor). With a clear localization of the neoplasm (conrmation of CT
or MRI studies is required), the operation provides a stable remission
in 70-80% of cases;
Destruction of the adrenal glands: the introduction of special scle-
rosing substances under the mandatory control of ultrasound or MRI
(such treatment is auxiliary);
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Proton therapy (directed irradiation of a pituitary tumor with pro-
tons) together with unilateral adrenalectomy (removal of one of the
adrenal glands).
2. Drug treatment.
Drugs that block the synthesis of adrenocorticotropic hormone.
Blockers of corticosteroid synthesis.
Destructors of cortical cells.
3. Medicines used in symptomatic therapy.
y Cushing’s syndrome treatment with antihypertensive drugs
(spironolactone, ACE inhibitors);
y hypoglycemic therapy (if the diagnosis has revealed signs of
excess glucose);
y sedatives and antidepressants;
y agents that reduce bone resorption (calcitonin);
y bisphosphonates;
y anabolic steroid.
4. Medical and labor expertise. Dispensary observation.
Disability group 1 is dened in a severe form of the disease
with pronounced hypotension, adynamia with a pronounced limita-
tion of life, leading to a pronounced social maladjustment due to the
impossibility of learning, communication, orientation, control over
one’s behavior, movement, self-service, participation in labor activi-
ties, if these violations cause the need for constant care or assistance.
2 group of disability is determined with signicantly pronounced
disabilities leading to social maladjustment due to the same reasons
as in the rst group, but while maintaining the ability to self-service,
severe endocrine hypothalamic-pituitary syndromes, with sharply and
signicantly expressed endocrine disorders or the development of vis-
ceral and other disorders.
Group 3 disability is determined in the presence of moderate or
mild endocrine disorders that restrict life activity and reduce the pos-
sibilities of social adaptation due to pronounced diculty in learn-
ing, communication, movement, as well as labor activity (reduced
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354
qualications or volume of work, diculty in performing professional
work due to anatomical defects).
Dispanserisation. Patients with Cushing’s syndrome are subject
to medical examination for life. They are examined by an endocrinol-
ogist, neurologist, ophthalmologist 4 times a year. X-ray of the skull is
performed 2 times a year, the content of somatotropin and glucose in
the blood is determined 4 times a year. If necessary, treatment contin-
ues with symptomatic means.
Clinical case No. 10
1. What is the preliminary diagnosis?
Acute adrenal insuciency associated with Addison’s disease.
2. What additional tests would you recommend to the patient,
and what are the expected results?
3. What is the patient’s management?
Treatment of the disease that caused decompensation. In acute
adrenal insuciency, hydrocortisone preparations are preferred (Hy-
drocortisone hemi succinate can be administered intravenously and
intramuscularly. Hydrocortisone acetate suspension is administered
only intramuscularly). Begin with the appointment of 100-150 mg
of hydrocortisone hemi succinate intravenously. The same amount of
the drug is dissolved in 500 mg of isotonic sodium chloride solution
and 5% glucose solution and injected intravenously over 3-4 hours
at a rate of 40-100 drops per minute. Simultaneously with the intra-
venous administration of water-soluble hydrocortisone, intramuscular
administration of Hydrocortisone 50-75 mg every 4-6 hours is per-
formed. The dose depends on the severity of the condition and the
results of increased blood pressure, normalization of electrolyte dis-
turbances. During the rst day, the total dose of hydrocortisone is 400-
600 mg, less often 800-1000, sometimes more. Intravenous admin-
istration of Hydrocortisone is continued until the collapse is cleared
and the blood pressure rises above 100 mm Hg. and continue its intra-
muscular administration 4-6 times a day at a dose of 50-75 mg with
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a gradual decrease in the dose to 25-50 mg and an increase in the
intervals of administration 2-4 times a day for 5-7 days. Then the pa-
tients are transferred to oral treatment with Prednisolone 10-20 mg per
day (hydrocortisone 30-40 mg per day), combined with the appoint-
ment of hydrocortisone 0.1-0.2 mg per day or cortisone acetate 25-50
mg per day. Along with the introduction of glucocorticoids, they ght
dehydration and shock phenomena. Isotonic sodium chloride solution
is poured in a volume of 2-3 liters per day. Due to the danger of hy-
poglycemia, at least 1 liter of 5-10% glucose solution is transfused.
Transfusion of potassium-containing solutions is categorically con-
traindicated. Etiological treatment aimed at eliminating the cause of
acute adrenal insuciency (antibiotic therapy).
4. Medical and labor expertise. Dispensary observation.
Disability group 1 is dened in a severe form of the disease with
pronounced hypotension, adynamic with a pronounced limitation of
life activity, leading to a pronounced social maladjustment due to the
impossibility of learning, communication, orientation, control over
one’s behavior, movement, self-service, participation in labor activi-
ties, if these disorders cause the need for constant care or assistance.
2 group of disability is determined with signicantly pronounced
disabilities leading to social maladjustment due to the same reasons
as in the rst group, but while maintaining the ability to self-service,
severe endocrine hypothalamic-pituitary syndromes, with sharply and
signicantly expressed endocrine disorders or the development of vis-
ceral and other disorders.
Group 3 disability is determined in the presence of moderate or
mild endocrine disorders that restrict life activity and reduce the pos-
sibilities of social adaptation due to pronounced diculty in learning,
communication, movement, as well as labor activity (reduced quali-
cations or volume of work, diculty in performing professional work
due to anatomical defects).
Prevention. The leading preventive measures to prevent the de-
velopment of acute adrenal insuciency are: motivation of the pa-
tient for regular and constant intake of corticosteroid drugs, under
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no circumstances can the drug be canceled. Timely recognition and
treatment of initial or subacute adrenal insuciency is essential to
prevent the progression of the crisis. The development of precursors
of a crisis or acute hypocorticism can be prevented in patients with
chronic hypocorticism during large and small surgical interventions of
infectious processes, during pregnancy, childbirth. For prophylactic
purposes, intravenous administration of glucocorticoids and deoxy-
corticosterone acetate preparations is prescribed in smaller doses than
with an Addison crisis. The day before the operation, hydrocortisone
is injected intramuscularly at 25-50 mg 2-4 times a day, deoxycor-
ticosterone acetate – 5 mg / day. On the day of surgery, the dose of
the drug is increased by 2-3 times. During surgery, hydrocortisone is
administered - 100-150 mg intravenously and 50 mg intramuscularly
every 4-6 hours for 1-2 days. Intravenous administration of hydrocor-
tisone continues after surgery for 2-3 days. Then they are gradually
transferred to replacement therapy with tablets of prednisolone, corti-
sone and deoxycorticosterone. At rst, the dose exceeds the usual one,
the duration depends on the general condition of the patient. When the
severity of the operational stress is eliminated, it is transferred to the
doses of drugs used before the operation.
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Chapter 13. HEMATOLOGY SECTION
Clinical case No. 1
Patient N, 32 years old, a designer, turned to the family doctor at
the polyclinic with complaints of an increase in body temperature up
to 39.4 ° C, a feeling of chills, general weakness, lethargy, sweating, as
well as the appearance of bleeding gums, the appearance of “bruises”
on the skin for no apparent reason. Considers himself sick for 8 days,
after physical overload, there was an increase in temperature. I took
paracetamol, aspirin, ibufen with a short-term eect. Weakness began
to grow progressively, bleeding and bruising appeared.
From the anamnesis of life: he denies the presence of chronic dis-
eases. Heredity is not burdened. Has a higher education. Goes in for
sports: running, swimming, cycling.
On objective examination: a state of moderate severity. Body
temperature 37.7 ° C. The skin is pale, high humidity. On the skin of
the lower extremities - ecchymosis; petechiae on the skin of the shoul-
ders, forearms; in the oral cavity - single petechial elements. On aus-
cultation, vesicular breathing, no wheezing. BR - 19 per minute. The
heart sounds are mued, the rhythm is regular. Heart rate - 92 beats
per minute. BP - 100/65 mm Hg. Art. The abdomen is soft and painless
on palpation. The edge of the liver is palpable 1 cm below the edge of
the costal arch, dimensions according to Kurlov - 16 × 10 × 9 cm. The
spleen is palpable, elastic, painless, percussion dimensions 10 × 8 cm.
Complete Blood Count: RBC – 2,3х10
12
/L, Нb –136 g/L,
MCH – 27 pg/cell, WBC – 28,9х10
9
/L, blasts - 32%, myelocytes -
0%, young neutrophils - 0%, neutrophils bands – 5%, neutrophils seg-
ments – 38%, lymphocytes – 25%, monocytes – 8%, eosinophil – 1%,
PLT – 30,0х10
9
/L, ESR – 30 mm/h.
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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, 73 years old, a notary, went to the polyclinic to see
a family doctor with complaints of muscle weakness, increased fa-
tigue, desire to sleep, a feeling of heaviness in the left hypochondrium,
a decrease in body weight by 7 kg over the last month.
History: arterial hypertension, duodenal ulcer. In childhood, I was
allergic to red food, allergic to metals like atopic dermatitis, seasonal
allergic rhinitis. From the anamnesis it is known that at the age of 42,
when the rst symptoms of the disease appeared, he was undergoing
inpatient treatment in the hematology department with a diagnosis of
“Acute leukemia. Primary attack “.
On objective examination. On examination, attention is drawn to
the increase in lymph nodes in the anterior surface of the neck, in the
supraclavicular and axillary cavities. The lymph nodes are painless,
relaxed, mobile, and have an elastic consistency. The spleen is en-
larged (+6 cm).
Complete Blood Count: RBC – 2,2х10
12
/L, Нb –97 g/L,
WBC – 31х10
9
/L, neutrophils bands – 6%, neutrophils segments –
67%, lymphocytes – 50%, monocytes – 8%, eosinophil – 4%, PLT –
130,0х10
9
/L, ESR – 16 mm/h. Gumprecht’s shadows are determined.
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
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Clinical case No. 3
Patient N, 48 years old, a web developer, complains of weakness,
lethargy, rapid fatigue, shortness of breath and palpitations with little
physical exertion, pallor of the skin, brittle nails, heavy menstruation.
From the anamnesis it is known that about 8 months ago, a gy-
necologist revealed a small uterine myoma, requiring only observa-
tion, while the patient’s menstruation became abundant. The rest of
the above complaints appeared 4 months ago with a slow increase;
noted an addiction to strong odors (gasoline, varnish, acetone), desire
to eat earth, walls, chalk; dizziness occasionally bothered. The patient
was not a donor. During three pregnancies and childbirth, mild anemia
was noted, which subsided in the postpartum period.
On objective examination: satisfactory condition, average nu-
trition. The skin and mucous membranes are moderately pale, there
are shallow cracks in the corners of the mouth, the nails are brittle,
with a pronounced longitudinal striation and emerging concavity. In
the lungs, vesicular breathing, no wheezing. Heart sounds are slightly
mued, rhythmic, systolic murmur is heard, conducted to the vessels,
heart rate is 78 beats per minute, blood pressure is 100/65 mm Hg. The
abdomen is soft, painless on palpation in all parts. The liver and spleen
are not palpable. Stool, urine output were unremarkable.
Complete Blood Count: RBC – 2,9х10
12
/L, Нb –68 g/L, MCH –
20 pg/cell, WBC – 3,8х10
9
/L, anisocytosis ++, poikilocytosis ++, mi-
crocytosis ++; neutrophils bands – 1%, neutrophils segments – 54%,
lymphocytes – 33%, monocytes – 6%, eosinophil – 5%, basophils -
1%, PLT – 200,0х10
9
/L, ESR – 15 mm/h.
General urine analysis is within normal limits.
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
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360
Clinical case No. 4
Patient N, 23 years old, a photographer, went to the clinic for an
appointment with a family doctor with complaints of weight loss, rap-
id fatigue, fever up to subfebrile numbers, a tendency to subcutaneous
hemorrhage, severe pain in the oral cavity and pharynx. Due to pain
when swallowing, it is dicult to eat and drink. Notes the lack of taste
in food, although the appetite is preserved. The patient considers him-
self within two weeks after receiving the procedures from the beauti-
cian, where the patient was cleansed and applied a moisturizing mask.
On objective examination: there are multiple small subcutane-
ous hemorrhages on the limbs. The mucous membranes of the mouth
and pharynx are hyperemic, bleed when touched, ulceration on the
gums, the tongue is coated, purulent plaque on the tonsils. Tempera-
ture 38.3 ° C. Pulse 88 beats. per min., BP 120/80 mm Hg., respiratory
rate 20 per min.
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. 5
Patient N, 67 years old, a clergyman, turned to a family doctor
at the polyclinic with complaints of general weakness, poor appetite,
diculty swallowing, shortness of breath with little physical exertion:
walking around the room, squatting. And also there were edema of the
legs, constant, slightly increasing in the evening.
Anamnesis of the disease: he considers himself ill about ve
months ago, when, after a trip to the mountains, the above complaints
began to appear. The polyclinic doctor, nding yellowness and pallor
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