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61
Clinical case No. 5
Patient N, 54 years old, a beekeeper, turned to the family doctor
at the polyclinic with complaints of headache in the occipital region,
vomiting, dizziness, ashing of ies before the eyes.
From the history it is known that the above complaints appeared
this afternoon. Before that, I had not been treated by a doctor. Head-
aches worried periodically for several years, but the patient did not
attach any importance to them and did not go to the doctors.
On objective examination: general condition of moderate sever-
ity. Body temperature 36.4 ° C. Consciousness is clear. Active po-
sition. Satisfactory nutrition. The skin is pale, clean. Subcutaneous
adipose tissue of homogeneous consistency, no edema and pastiness.
Hair and nails are not changed. The thyroid gland is not visually deter-
mined, on palpation of a soft-elastic consistency, painless. Peripheral
lymph nodes are not enlarged. The muscular system is well developed.
The joints are not externally changed. Vesicular breathing, no wheez-
ing, respiratory rate 13 per minute. The left border of relative cardiac
dullness is 1 cm outward from the midclavicular line. Mued heart
sounds, pronounced emphasis of the 2nd tone on the aorta. Heart rate
92 / min., Pulse is rm, tense. Blood pressure 200/110 mm Hg. On pal-
pation, the abdomen is soft, painless. Percussion borders of the liver
are within normal limits. The gallbladder is not palpable; palpation in
its projection is painless. Stool and urine output are normal.
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. 6
Patient N, 46 years old, a winemaker, turned to the family doctor
at the polyclinic with complaints of weakness, intense pressing pains
behind the sternum radiating to the left shoulder, lasting for 2 hours,
not removed by taking nitroglycerin, interruptions in the work of the
heart, a sharp general weakness, cold clammy sweat.
From the anamnesis it is known that the day before the above
complaints, the patient worked excessively physically. In the anam-
nesis - within 4-5 years, notes attacks of squeezing pains behind the
sternum during brisk walking, lasting 3-5 minutes, passing at rest and
after taking nitroglycerin.
On objective examination: general condition of moderate severi-
ty. Body temperature 36.7 ° C. Consciousness is clear. Active position.
Satisfactory nutrition. Pale skin, acrocyanosis, moist palms. Pulse 96
per minute. Subcutaneous adipose tissue of homogeneous consistency,
no edema and pastiness. Hair and nails are not changed. The thyroid
gland is not visually determined, on palpation of a soft-elastic consis-
tency, painless. Peripheral lymph nodes are not enlarged. The muscu-
lar system is well developed. The joints are not externally changed.
The cardiovascular system. The borders of the heart are expanded to
the left by 1.5 cm. Deaf tones, single extrasystoles. Blood pressure
90/60 mm Hg. Respiratory system. On examination, normal shape of
the chest, symmetrical. With comparative percussion over the entire
surface of the lungs, a pulmonary sound is determined. Respiratory
rate - 19 in 1 min. At auscultation over the lungs, vesicular breathing
is determined on both sides, wheezing is not heard. On palpation, the
abdomen is soft, painless. Percussion borders of the liver are within
normal limits. The gallbladder is not palpable; palpation in its projec-
tion is painless. Stool and urine output are normal.
Complete Blood Count: RBC – 4,3х10
12
/L, Нb –136 g/L, MCH –
27 pg/cell, WBC – 9,2х10
9
/L, neutrophils bands – 4%, neutrophils
segments – 66%, lymphocytes – 23%, monocytes – 7%, eosinophil –
1%, PLT – 214,0х10
9
/L, ESR – 10 mm/h.
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63
Blood serum: CRB +, LDH 360 U / L, CPK 2.4 mmol / hl, AST
24 U / L, ALT 16 U / L. PTI - 100%.
Complete blood count on the sixth day from the onset of pain:
RBC – 4,6х10
12
/L, Нb –136 g/L, MCH – 27 pg/cell, WBC – 6,0х10
9
/L,
neutrophils bands – 2%, neutrophils segments – 64%, lymphocytes –
24%, monocytes – 9%, eosinophil – 1%, PLT – 214,0х10
9
/L, ESR –24
mm/h.
On the ECG - the rhythm is non-sinus, the rhythm is correct, the
electrical axis of the heart is not determined. Heart rate 80 beats per
minute, ST segment elevation and Q waves in leads II, III, aVF, V1,
V2, V3, V4.
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. 7
Patient N, 62 years old, interior designer, turned to the family
doctor at the polyclinic with complaints of a sensation of frequent
irregular heartbeat accompanied by weakness and unpleasant sensa-
tions in the region of the heart.
From the anamnesis it is known that similar sensations of palpi-
tations, notes more often during exercise, notes during the last year.
These episodes were short-lived and passed on their own at rest.
When analyzing the outpatient card over the past 2 years, an increased
cholesterol content was repeatedly revealed (total cholesterol up to
7.6 mmol / l, LDL - 3.36 mmol / l).
On objective examination: general condition of moderate sever-
ity. Body temperature 36.7 ° C. Consciousness is clear. Active posi-
tion. Satisfactory nutrition. The skin is somewhat pale, hypersthene
type of constitution, high humidity. Subcutaneous adipose tissue of
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64
homogeneous consistency, no edema and pastiness. Hair and nails are
not changed. The thyroid gland is not visually determined, on palpa-
tion of a soft-elastic consistency, painless. Peripheral lymph nodes are
not enlarged. The muscular system is well developed. The joints are
not externally changed. The cardiovascular system. BP - 150/100 mm
Hg. The pulse on the radial arteries is frequent, arrhythmic, the fre-
quency is 102 per minute. Heart sounds at the apex have inconsistent
sonority, arrhythmic, heart rate - 112 in 1 minute. Respiratory system.
On examination, normal shape of the chest, symmetrical. With com-
parative percussion over the entire surface of the lungs, a pulmonary
sound is determined. BH - 19 in 1 min. At auscultation over the lungs,
vesicular breathing is determined on both sides, wheezing is not heard.
On palpation, the abdomen is soft, painless. Percussion borders of the
liver are within normal limits. The gallbladder is not palpable; palpa-
tion in its projection is painless. Stool and urine output are normal.
Complete Blood Count: RBC – 4,5х10
12
/L, Нb –140 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 – 6 mm/h.
General urine analysis - beats. weight - 1020, no protein, no sug-
ar, l - 1-2 p / sp.
Blood test for sugar - blood glucose - 4.5 mmol / l.
Blood for cholesterol - 7.6 mmol / l, AST - 5 units / l, ALT -
4 units / l, CRP - 0, PTI - 102%, coagulation - 8 minutes. The fundus
of the eye - atherosclerosis of the retinal vessels.
Echocardiography: the average pulmonary arterial pressure – 23
mm Hg. The left atrium is 3.2 cm. Left ventricular diastolic size of
course is 5.0 cm. The systolic size is 3.0 cm. EF is 68%. The thickness
of the posterior wall of the left ventricle is 1.0 sm. The thickness of the
IVS is 0.7 cm. The right ventricle is 2.4 cm. The anterior wall of the
right ventricle - 0.3 cm.
Questions:
1. What is the preliminary diagnosis?
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65
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. 8
Patient N, 16 years old, a stuntman, turned to the family doctor at
the polyclinic with complaints of an increase in blood pressure up to
180/120 mm Hg. Art., and also disturbed by headaches, nosebleeds,
pain in the legs after a long walk.
On objective examination: hypersthenic constitution of the pa-
tient, developed shoulder girdle, hyperemia of the face. The pulse on
the radial artery is tense, rhythmic with a frequency of 64 per minute.
In the lungs, vesicular breathing, no wheezing. The left border of the
heart is 2 cm outward from the left mid-clavicular line. Heart sounds
are rhythmic, sonorous, at all points of auscultation, a rough systolic
murmur is heard, conducted on the vessels of the neck and in the in-
terscapular space. BP on the brachial artery - 170/110 mm Hg., on
the femoral artery - 150/80 mm Hg. Art. The liver and spleen are not
palpable. The lower extremities are cold, pale, the pulsation of the
vessels is weak.
Complete Blood Count: RBC – 4,7х10
12
/L, Нb –136 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 – 8 mm/h.
ASL-O - 63 units. , DPA - 180 units, brinogen - 220 units, al-
bumin - 60%, alpha-1-globulins - 4%, alpha-2-globulins - 7%, beta-
globulins - 10%, gamma globulins - 19%.
Echocardiography: the average pulmonary arterial pressure – 25
mm Hg. The left atrium is 3.8 cm. Left ventricular diastolic size of
course is 5.0 cm. The systolic size is 3.0 cm. EF is 68%. The thickness
of the posterior wall of the left ventricle is 2.0 sm. The thickness of the
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66
IVS is 0.7 cm. The right ventricle is 2.4 cm. The anterior wall of the
right ventricle - 0.3 cm.
Aortography: narrowing of the aortic isthmus.
Kidney ultrasound: no pathological changes.
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. 9
Patient N, 55 years old, a cameraman, turned to the family doctor
at the polyclinic with complaints of headache in the parieto-occipital
region in the morning, dizziness, stabbing heart pain, poor sleep, gen-
eral weakness.
From the anamnesis it is known that the patient has been ill for
2 months.
On objective examination: satisfactory condition, increased nutri-
tion, facial skin is hyperemic. Body temperature 36.7 ° C. Conscious-
ness is clear. Active position. Subcutaneous adipose tissue of homoge-
neous consistency, there is no edema. Hair and nails are not changed.
The thyroid gland is not visually determined, on palpation of a soft-
elastic consistency, painless. Peripheral lymph nodes are not enlarged.
The muscular system is well developed. The joints are not externally
changed. In the lungs, vesicular breathing, no wheezing. Pulse - 90
in 1 min., Rhythmic, tense. BP on both arms is 180/100 mm Hg. The
left border of the heart is 1.0 cm inward from the left mid-clavicular
line, the right and upper are normal. Heart sounds at the top are muf-
ed. P tone is accentuated on the aorta. On palpation, the abdomen is
soft, painless. Percussion borders of the liver are within normal limits.
The gallbladder is not palpable; palpation in its projection is painless.
Stool and urine output are normal.
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67
1. Complete Blood Count: RBC – 4,9х10
12
/L, Нb –130 g/L,
MCH – 27 pg/cell, WBC – 6,0х10
9
/L, neutrophils bands – 2%, neu-
trophils segments – 60%, lymphocytes – 30%, monocytes – 8%, eo-
sinophil – 1%, PLT – 300,0х10
9
/L, ESR – 8 mm/h.
2. General urine analysis: light yellow, acid reaction, complete
transparency, beats. weight - 1023, no protein and sugar, watering can.
- 0-2 in p / sp. er. - 1-2 in p / sp., No cylinders.
3.Urine analysis according to Zimnitsky: beats. weight from 1008
to 1027, daytime diuresis - 800.0 ml, nighttime diuresis - 500.0 ml.
4. Urine analysis according to Nechiporenko: in 1 ml of urine er.
- 800, lake. - 1000, cylinders - 18.
5. Rehberg’s test: glomerular ltration - 100 ml / min, tubular
reabsorption - 98%.
6. Blood tests: creatinine - 0.088 mmol / L, cholesterol - 5.5 mmol
/ L, triglycerides - 1.5 mmol / L, beta-lipoproteins - 4.5 g / L, PTI - 100
units
7. Echocardiography: Left ventricular diastolic size is 6.0 cm.
EF is 65%. The thickness of the posterior wall of the left ventricle is
2.0 sm.
8. Ultrasound of the kidneys - kidneys of normal size, the renal
pelvis is not changed, calculus is not detected.
9. Radioisotope renography - the absorption and excretory func-
tions of the kidneys are not impaired.
10. The fundus of the eye - some narrowing of the arteries.
11. Neurologist’s consultation - functional disorder of the nervous
system.
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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68
Clinical case No. 10
Patient N, 37 years old, art director, turned to the family doctor at
the polyclinic with complaints of severe chest pains, severe dyspnea
of a mixed nature. She suddenly lost consciousness.
From the anamnesis it is known that the patient has been observed
by a surgeon for 12 years with deep vein thrombosis of the lower
extremities, accompanied by thrombophlebitis; and also the patient
has been suering from grade 2 hypertension for 20 years. Heredity
is burdened by the mother: hypertension, grade 3, very high risk. Bad
habits: smoking 1 pack of cigarettes per day.
On objective examination: the general condition is severe, con-
sciousness is absent, there is a blue-purple cyanosis of the upper body.
Shallow breathing up to 50 per minute. On auscultation, breathing in
the right half of the chest is sharply weakened, single dry wheezing,
in the lower parts of the lower parts of the small bubbling rales. The
cervical veins are swollen, the pulse is threadlike 100 per minute. BP
- 90/40 mm Hg. Dull heart sounds, splitting of the second tone over
the pulmonary artery. The thyroid gland is not visually determined,
on palpation of a soft-elastic consistency, painless. Peripheral lymph
nodes are not enlarged. The muscular system is well developed. The
joints are not externally changed. The abdomen is enlarged, palpa-
tion is not available. Percussion borders of the liver are within normal
limits. The gallbladder is not palpable; palpation in its projection is
painless. Stool and urine output are normal.
Complete Blood Count(Cito): RBC – 4,5х10
12
/L, Нb –135 g/L,
MCH – 27 pg/cell, WBC – 9,5х10
9
/L, neutrophils bands – 2%, neu-
trophils segments – 65%, lymphocytes – 21%, monocytes – 10%, eo-
sinophil – 2%, PLT – 214,0х10
9
/L, ESR – 15 mm/h.
Urinalysis (Cito): straw yellow, sour reaction, beats. weight -
1016, leukocytes - 1-2 in eld of vision, ep. cells - 1-2 in p / sp.
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69
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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70
Chapter 4. STANDARD OF ANSWERS
FOR THE CARDIOLOGY SECTION
Clinical case No.1
1. Formulate a preliminary diagnosis. Coronary heart disease.,
Stable exertional angina, FC II, postinfarction cardiosclerosis and cir-
culatory failure.
Concomitant diagnosis: chronic lumbosacral radiculitis in remis-
sion
2. Assign additional research methods.
Laboratory tests
Basic examination in patients with coronary artery disease in-
cludes standard biochemical tests: troponin T or I level, complete
blood count with determination of hemoglobin and leukocyte count,
glycated hemoglobin and plasma glucose fasting, serum creatinine and
creatinine clearance, blood lipid, thyroid function, liver function tests,
creatinine phosphokinase, brain natriuretic peptide type B (BNP) or
GC-B, peptide hormone and its precursor ( BNP / NT-proBNP).
Instrumental studies
Electrocardiogram (ECG) at rest and / or during or immediately
after an attack of chest pain, outpatient ECG monitoring (in patients
with suspected arrhythmia and vasospastic angina), echocardiogra-
phy at rest to identify violations of regional contractility, determina-
tion of ejection fractions and assessment diastolic function of the left
ventricle, ultrasound examination of the carotid arteries to determine
the thickness of the intima media and / or detection of atherosclerotic
plaques, chest X-ray.
Studies according to indications
Non-invasive methods for diagnosing ischemia:
t.me/medicina_free
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