SITUATIONAL Task of Emergency 1
Patient 48 years old, complains of dyspnoea, cough with foamy and bloody sputum. According to the patient, he has been suffering from heart defects for 15 years. In last 2-3 months, condition became worst, dyspnoea on moderate physical exertion, dry cough that arises on horizontal position.
Objective: orthopnea, acrocyanosis, respiratory rate - 28 per minute, muscles take part in respiration. Auscultation of lungs: moist rales of different intensity on all points of lungs. Heart sounds are rhythmic, 1st sound is increased, diastolic pre-systolic murmur is auscultated on apex, pulse rate - 120 beats per min, BP - 140/80 mm Hg. Abdomen is soft and painless. Liver is not increased. Peripheral edema is absent.
No 1:
1. Acute LV insufficiency
2. Oxygen inhalation through 70% spirit (antifoamsilane), morphine 1% - 1ml I/V, nitroglycerine 1% - 2ml in 200ml of 0.9% NaCl I/V drops, furosemide (lasix) 40-80 mg I/V
SITUATIONAL TASK OF EMERGENCY 2
Patient 54 years old was hospitalized in intensive care unit with expressed dyspnoea. 3 years ago he had Q-wave myocardial infarction, complicated by aneurysm of anterior wall of LV.
Objective: cyanosis of skin and mucous membranes, acrocyanosis. Orthopnea position. Auscultation of heart: rough systolic murmur on apex. HR - 110 beats/min, BP - 170/100 mm Hg. Percussion of lungs: expressed dull sound of lower parts of both lungs. Auscultation of lungs: large amount of small and medium bubble rales on all part of lungs. Liver is enlarged on 4 cm. Edema of lower extremities. ECG is without dynamic changes.
No 2:
1. Acute LV insufficiency
2. Oxygen inhalation through 70% spirit (antifoamsilane), morphine 1% - 1ml I/V, nitroglycerine 1% - 2ml in 200ml of 0.9% NaCl I/V drops, furosemide (lasix) 40-80 mg I/V
SITUATIONAL TASK OF EMERGENCY 3
Patient 64 years old had intensive retrosternal pain, expressed weakness and feeling of fear during 7 hours. For the past 8 years he has been suffering from angina pectoris. Last 2 weeks after emotional stress condition became worse, retrosternal pain appeared during mild physical exertion, sometimes at rest, he consumed 6 tablets of nitroglycerin per day.
Objective: adynamia, skin is pale, cold sweat. Pulse - 108 beats/min, weak filling, rhythmic. BP - 70/50 mm Hg. Auscultation: harsh breathing, small bubble rales in lower parts of lungs. Heart sounds are decreased and rhythmic. HR - 96 beats per min. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG:
No 3:
1. Acute Q-wave myocardial infarction of anterior-lateral wall of LV, cardiogenic shock.
2. Morphine 1% - 1ml I/V, oxygen inhalation, aspirin, heparin 5-10 thousand IU I/V, then 1000 IU/hour I/V drops 48-72 hours, dopamine I/V drops 2-4 mcg/kg/min, if not effective – prednisolone
SITUATIONAL TASK OF EMERGENCY 4
Patient 66 years old came to polyclinic with complaints on dizziness, general weakness and walks like a drunken person. 2 days ago he lost his consciousness for a short period of time.
Objective: moderate severe condition, skin and mucous membranes of usual color. Auscultation: vesicular breathing, no rales. Heart sounds are decreased, rhythmic, HR - 43 per min. BP - 140/90 mm Hg. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. During inspection: sudden loss of consciousness for few seconds. Skin is pale. Pulse - 30 beats/min, rhythmic. On presented ECG:
No 4:
1. Complete AV block with frequency of ventricular rhythm 30 per min.
2. Atropine sulphate 0.1% - 0.5-1 ml I/V, temporary pacemaker implantation (if loss of consciousness repeats), preparation for permanent pacemaker implantation
SITUATIONAL TASK OF EMERGENCY 5
Patient 67 years old visited polyclinic with complaints on dizziness, general weakness, twice loss of consciousness. 4 years ago he had myocardial infarction.
Objective: moderate severe condition, skin and mucous membranes of usual color. Auscultation: vesicular respiration, no rales. Heart sounds are decreased and arrhythmic, HR - 62 per min. BP - 140/90 mm Hg. Abdomen is soft and painless. Liver not enlarged. Peripheral edema is absent. On 24-hours monitoring of ECG: episodes of AV blockade II degree, Mobitz 2 (2:1-4:1), frequent periods of ventricular asystoly with maximal duration of 3.5 seconds. During inspection he suddenly lost of consciousness. Skin is pale. Pulse and BP are not determined.
No 5:
1. Morgagnie-Adams-Stoks syndrome connecting with AV block II stage Mobitz 2
2. Close massage of heart and artificial ventilation of lungs, atropine sulphate 0.1% - 1 ml I/V, temporary pacemaker, preparation for permanent pacemaker implantation
SITUATIONAL TASK OF EMERGENCY 6
60 years old male patient, hospitalized in intensive care unit in 4 hours after beginning attacks of retrosternal pain.
Objective: skin is pale. Auscultation: vesicular respiration and no rales. Heart sounds are decreased and arrhythmic. HR - 96 beats per min. BP - 110/70 mm Hg. Abdomen is soft and painless. Liver not enlarged. Peripheral edema is absent. On showed ECG: sinus rhythm, frequent polyfocal ventricular extrasystoly, pathologic Q wave in І, aVL; QS in V1, V2, V3 leads, dome-shaped elevation of ST segment, negative T wave. During ECG investigation patient lost consciousness suddenly, wheezed, tonic convulsions appeared. Breathing is absent, pulse and BP are not determined. On ECG:
No 6:
1. Acute Q-wave myocardial infraction of anterior-septal wall of LV, ventricular fibrillation
2. Punch to the sternum region, closed massage of heart and artificial ventilation of lungs, electric cardioversion, Lidocaine, morphine, oxygen inhalation, aspirin, streptokinase or alteplase I/V, heparin. If there is increase in systolic pressure more than 100-110 mm Hg - nitroglycerine I/V drops
SITUATIONAL TASK OF EMERGENCY 7
Patient 28 years old had sudden feeling of fear, anxiety and palpitation. In anamnesis about 6 years patient had similar attacks of anxiety and palpitation, which reduced by itself in 10-30 min.
Objective: moderate severe condition, skin and mucous membranes of usual color. Auscultation: vesicular respiration and no rales. Heart sounds are decreased, rhythmic, HR - 180 per min. BP - 130/80 mm Hg. Abdomen is soft and painless. Liver not enlarged. Peripheral edema is absent. On ECG:
No 7:
1. Paroxysmal AV-node tachycardia
2. Reflectory methods – Valsalver's maneuver (holding of inspiration with straining effort), carotid sinus massage in the medial border of m.sternocleidomastoideus at the level of upper border of thyroid cartilage, adenosin 1% – 1-2ml I/V during 5-10sec., or verapamil I/V 0.25% - 2-4ml in 10ml of NaCl, if not effective (or maybe immediately) –transesophageal electrocardiostimulation
SITUATIONAL TASK OF EMERGENCY 8
Patient 58 years old complains of severe palpitation, dizziness and discomfort in retrosternal region. In anamnesis about 6 years patient suffered from ischemic heart disease.
Objective: moderate severe condition, pale skin. Respiratory rate - 24 per min, superficial respiration. Auscultation: harsh breathing, single small bubble rales in lower parts of lungs. Heart sounds are decreased, rhythmic, HR - 146 per min. BP - 140/80 mm Hg. Pulse - 146 beats/min, week filling. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG:
No 8:
1. Paroxysmal ventricular tachycardia
2. Lidocaine – 2% - 4-6ml in 10ml of NaCl I/V, if not effective – amiodarone I/V, if medicamentous treatment not effective and development of acute LV insufficiency - electric cardioversion
SITUATIONAL TASK OF EMERGENCY 9
Patient 58 years old for a period of few hours had intensive headache, nausea, consumed analgin tablet but there was no effect. About 1 hour ago he had retrosternal pressing pain. For the past 8 years he had been suffering from episodes of increase arterial pressure.
Objective: moderate severe condition, skin is hyperemic. Auscultation - vesicular respiration, no rales. Heart sounds are decreased, rhythmic, HR - 92 per min. BP - 190/100 mm Hg. Abdomen is soft and painless. Liver not enlarged. Edema is absent. On ECG:
No 9:
1. Hypertensive crisis, complicated by acute myocardial infarction
2. Nitroglycerine 1%-2ml in 200ml of NaCl, morphine 1%-1-2ml I/V, oxygen inhalation, aspirin, streptokinase or actilise (alteplase) I/V, heparin
SITUATIONAL TASK OF EMERGENCY 10
Patient 53 years old complains of intensive headache, dizziness, nausea, dull pain in heart region, disturbance of in heart action. The condition became worst after stress situation. Increase of BP for the past 3 years.
Objective: face is hyperemic, pulse rate - 85 beats/min, BP - 210/115 mm Hg. Auscultation: vesicular breathing and no rales. Heart border shift to left on 1.5cm. On apex heart sounds are clear, accent 2nd tone on aorta. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG - sinus rhythm, HR - 85 per min, single supraventricular extrasystoly, signs of LV hypertrophy with systolic overload.
No 10:
1. Hypertensive crisis, non-complicated
2. Nifedipine 10mg sublingually or captopril 25-50mg sublingually
SITUATIONAL TASK OF EMERGENCY 11
Patient 46 years old complains of expressed dizziness, sudden weakness. For the past 4 years he had episodes of increase arterial pressure. About 1.5 hours ago, after emotional stress he had intensive headache, stabbing pain in a heart region, he took 10mg of nifedipine and nitroglycerin sublingually. After 10 minutes there was no improvement in his condition, he took 2 tablets of nitroglycerin and 50mg of captopril. After 1 hour when he get up from his bed he briefly lost consciousness (syncope).
Objective: moderate severe condition, pale skin. Auscultation: vesicular respiration, no rales. Heart sounds are decreased, rhythmic, HR - 98 per min. Ps - 98 beats/min with weak filling. BP - 70/40 mm Hg. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG: sinus rhythm, HR - 100 per min, signs of LV hypertrophy.
No 11:
1. Medicamentous collapse
2. Stop of intake of drug preparations, horizontal position of patient, mesatone 1% - 0.5ml I/V
SITUATIONAL TASK OF EMERGENCY 15
54 years old patient is delivered to the hospital in an unconscious state.
Objectively: unconscious state, on painful irritation reaction patient had in-coordinate movements of extremities. Corneal and knee reflexes are depressed. Skin and visible mucous membranes are dry, noisy frequent respiration, "fruity" odor from mouth. Auscultation: vesicular respiration, no rales. Heart sounds are decreased, rhythmic, HR - 60 per min.
Laboratory data: hematocrit - 0.56, blood glucose - 19.5 mmol/l, positive ketone bodies in urine, plasma potassium - 2.75 mmol/l. BP - 110/70 mm Hg. Abdomen is soft and painless.
No 15:
1. Ketoacidosis coma, developed due to decompensation of diabetes mellitus
2. Parenteral insulin therapy under the control of glycemia, rehydration, correction level of electrolytes and acid-base status of plasma
SITUATIONAL TASK OF EMERGENCY 17
A man about 50 years old suddenly lost consciousness while working.
Objectively: unconscious state, pale skin, spontaneous respiration is absent, pupils are dilated and pulse on carotid artery is absent. It is known, that the patient was under observation in a polyclinic due to ischemic heart disease.
Determine the emergency
Provide first aid
No 17:
1. Cardio-respiratory arrest, it is probably as a result of asystoly or ventricular fibrillation
2. Punch to the sternum region, closed massage of heart and artificial ventilation of lungs, electric cardioversion, transportation to hospital.
SITUATIONAL TASK OF EMERGENCY 20
A 23 year old patient, who was under severe alcohol intoxication, slept in squatting position more than 6 hours. In two days, he came to the hospital with complaints on nausea, vomiting, disorder of sensitivity and movements, expressed edema in lower extremities and absence of urination.
Objectively: moderate severe condition, pale skin, dry tongue with white coating. Auscultation: vesicular respiration, no rales. Heart sounds are decreased, rhythmic, HR - 100 per min, BP - 150/100 mm Hg, Significant edema of hip and feet, absent sensitivity on the lower then upper third of thigh and impaired voluntary movements of leg. On catheterization of urinary bladder - 100 ml of urine (brown color). Laboratory data: plasma urea – 8,2 mmol/l, creatinin – 0,726 mmol/l, plasma potassium - 7.0 mmol/l.
No 20:
1. Crush (compression) syndrome that led to acute renal insufficiency.
2. Hemodialysis
SITUATIONAL TASK OF EMERGENCY 21
Patient 40 years old was delivered by ambulance to the hospital after using of unknown mushrooms 5 days ago. Previous day patient had nasal bleeding.
Objectively: clouded consciousness. Skin is icteric, turgor is decreased. Auscultation: vesicular respiration and no rales. Heart sounds are decreased and rhythmic. HR - 58 per min. BP - 90/60 mm Hg. Liver border along the midclavicular line is on 4 cm below rib arch. Laboratory date: hemoglobin – 95 g/l, blood glucose – 3 mmol/l, general protein – 45 g/l, general bilirubin – 180 mcmol/l, direct bilirubin – 60 mcmol/l, ALT - 4.5 mmol/l, AST – 7 mmol/l, prothrombin index – 45%.
No 21:
1. Acute hepatic insufficiency due to use of poisonous mushrooms in food (it is probable - death-cup)
2. Correction of blood sugar - I/V infusion of glucose solution, hypoproteinemia - I/V albumin, hemostasis indexes - I/V fresh frozen plasma. Detoxication - forced diuresis, enterosorbents and hemodialysis.
SITUATIONAL TASK OF EMERGENCY 22
A male patient 59 years old with acute myocardial infarction was brought to the hospital by an ambulance. In reception, condition of the patient has worsened, he complains of anxiety, feeling of severe breathlessness.
Objectively: skin is pale, orthopnoe, noisy respiration, moist rales can be heard on a distance, cough with foamy pink sputum. Auscultation: harsh breathing, moist rales over all parts of lungs. Heart sounds are decreased and rhythmic. HR - 96 beats per min. BP - 140/90 mm Hg Abdomen is soft and painless.
No 22:
1. Acute myocardial infarction, complication – acute LV insufficiency (pulmonary edema)
2. Oxygen inhalation through 70% spirit (antifoamsilane), morphine 1% - 1ml I/V, nitroglycerine 1% - 2ml in 200ml of 0.9% NaCl I/V drops, furosemide (lasix) 40-80 mg I/V
SITUATIONAL TASK OF EMERGENCY 27
To relieve headache a young woman took 1 tablet of analgin per os. In few minutes she was appeared edema of face, eyelids and neck, which progressed, difficult noisy respiration, hoarse voice.
No 27:
1. Quinke’s edema
2. Begin with adrenaline 0.1% solution 0.5-0.7ml I/V, then continue with infusion (drops), glucocorticoids and antihistamine preparations are included in the complex therapy. Acute respiratory insufficiency - oxygen therapy. If no effect and progressing of respiratory insufficiency - intubation of trachea and artificial ventilation of lungs
SITUATIONAL TASK OF EMERGENCY 31
Puerperant female, 29-year-old, has hypotonic metrorrhagia. Blood loss volume is about 1.5 liter. Bleeding was stopped after massage of uterus on clinched fist and oxitocyn.
General condition is severe, clammy sweat, tachypnea, respiration rate – 30 per min. BP – 70/40 mm Hg, pulse rate – 120 per min., pulse is rhythmic, weak and rapid. Acrocyanosis. Diuresis – 30 ml/hour.
CBC: Hb – 95 g/l, Pl. – 120 x 109/l. Ht – 30%
No 31:
1. Puerperal period. Hypotonic metrorrhagia. Post hemorrhagic shock of 2-nd stage (moderate).
2. 100% Oxygen inhalation. 1-2 Central veins catheterization. Crystalloids and colloid solutions. Blood preparations. In case of systemic acidosis – sodium solution infusion under the control of pH.
SITUATIONAL TASK OF EMERGENCY 32
Male patient 28-year-old suffering from Willebrand's disease was delivered to the hospital with closed injury of thorax after automobile accident. He complains on pain in thorax, dyspnea.
In anamnesis: predisposition to gingival hemorrhage, epistaxis, bruise and hematomas appearance after trivial trauma from the childhood.
Survey: Acrocyanosis, respiration rate – 30 per min. Dull sound under percussion of right side of the thorax, respiratory murmurs are not heard; Bp – 100/50 mm Hg, pulse rate – 110 per min., pulse is weak and rapid.
In X-ray examination: fracture of 3 ribs in the right side of the thorax, horizontal-level shadow up to 4-th rib in the right side.
No 32:
1. Closed injury of the thorax: ribs fracture, right side traumatic hemathorax. Post hemorrhagic shock, I stage. Von Willebrand's disease.
2. 100% Oxygen inhalation. Infusion of cryoprecipitate (400-600 Un) or purified concentrates of eights factor, contain von Willebrand’s factor, each 12 hours. Desmopressin, fresh frozen plasma, crystalloid solutions. Aspiration of blood from thoracic cavity, drainage.
SITUATIONAL TASK OF EMERGENCY 33
Woman 23 years old was transmitted from therapeutic department to reanimation department due to worsen condition.
During examination: position is forced, orthopnea, patient is exited. Respiration rate is 42 per min with help of additional mussels, acrocyanosis, mobility of the lungs is limited. Auscultation: a lot of dry rales. In the lower parts of the lungs the respiration is weak sharply, sometimes absent. Pulse rate 120-130 beats per min. BP – 160/100 mm Hg.
Conservative therapy with Euphylline, Prednisolone 100 mg per os - without effect.
No 33:
1. Asthmatic status
2. Oxygen inhalation, inhalation of β2 agonists, prednisolone 2-3 mg/kg I/V in drops, euphylline 2,4% - 10-15 ml I/V, rehydration, correction level of pH, if needs – bronchial lavage
SITUATIONAL TASK OF EMERGENCY 34
In a man, 45 years old, during making physical exertion suddenly acute pain appeared on the left side of the chest, marked breathlessness, dry cough.
Objectively: Pale skin covered by cold perspiration, marked cyanosis, backwardness of the left side of the chest of the respiration act. Percussion: tympanic sound on the left side of the lungs. Auscultation: weak respiration on the left. On x-ray examination: pulmonary picture is absent on the left side, displacement of the mediastinum to the right.
No 34:
1. Spontaneous pneumothorax.
2. Puncture and drainage of pleura cavity in the third-fourth intercostals space on midclavicular line and aspiration of air. Anesthesia
SITUATIONAL TASK OF EMERGENCY 36
A 37 years old patient was operated because of oophoritic cyst’s rapture complicated by the bleeding within 2 liters. During operation, hypotonic onset was noticed for 30 minutes; at the time of the day after operation, she had 300 ml of urine and diuretic challenge didn’t bring any results.
CBC: RBC – 2,4*1012 /L, hemoglobin 86 g/L, ESR 54 mm/h, blood serum creatinine 268 mcmol/L, urea 10 mmol/L, potassium 6.0 mmol/L. Urinalyses: specific density 1008, protein 1.65 g/L, WBC 80-100 in the field of vision, altered RBC 8-10 in the field of vision, hyaline cylinders 5-6 in the field of vision.
No 36:
1. Acute renal insufficiency is developed as a result of lingering renal blood supply dysfunction due to grave loss of blood and decrease of blood pressure.
2. Rehydration, blood preparations I/V.; decrease blood potassium volume: glucosae-insuline mixture I/V.; improve kidney blood supply – dopamine 1-3 mkg/kg/min; excrete nitrous slag by GIT – lactulose, laxatives. In case of inefficiency of these measures – use haemodialysis.
SITUATIONAL TASK OF EMERGENCY 37
A 46 years-old patient, a day after operation because of hydronephrosis of the right kidney. He excreted 110 ml of urine, diuretic challenge is not effective. Physical examination revealed pale, dry skin, rough breathing sounds; heart sounds are decreased, rhythmic. BP is 190/130 mm Hg, pulse 110 bpm. Blood serum creatinine 270 mcmol/L, urea 14 mmol/L, potassium 7.0 mmol/L.
No 37:
1. Acute renal insufficiency.
2. Limit the volume of liquids given I/V.; decrease blood potassium volume: glucosae-insuline mixture I/V.; improve kidney blood supply – dopamine 1-3 mkg/kg/min; excrete nitrous slag by GIT – lactulose, laxatives. In case of inefficiency of these measures – use haemodialysis.
SITUATIONAL TASK OF EMERGENCY 38
A 45 years-old patient is referred to nephrology department in the occasion of nephritis’ exacerbation. On examinations he looks grave, signs of dormancy, skin is pale and dry, with scratches; fibrillic muscular twitching, tendinous reflexes are normal; smell of urea. Breathing is arrhythmic; heart sounds are suppressed, pericardial friction rub, BP 180/110 mm Hg, pulse 42 bpm.
CBC: RBC – 2,8*1012 /L, hemoglobin 60 g/L, blood serum creatinine 0,726 mmol/L, urea 25 mmol/L, potassium 4.5 mmol/L. Urinalyses: volume – 250 ml/day, specific density 1005, protein 1.2 g/L, RBC 5-7 in the field of vision, granular cylinders 2-3 in the field of vision.
No 38:
1. Chronic renal insufficiency, terminal stage, uraemic pericarditis.
2. Heamodialysis. Acidosis treatment - gastric lavage, sodium hydrocarbonate and dextrose-insuline mixture I/V; antihypertensive care - calcium channel blockers (amlodipin), diuretics (torasemide, furosemide), treatment of anaemia – fresh cleaned erythrocytes (if PCV is less 30%), erythropoietin; decrease of spasmodic syndrome- clyster with 50 ml 30% chloral hydrate.
SITUATIONAL TASK OF EMERGENCY 44
Patient В., 62 years, abuses alcohol. During 3 days he took alcoholic drinks of doubtful quality.
Objective: unconscious. Spontaneous locomotion, reaction to pain irritants, pupillary tests are absent. There are pathological (plantar) reflexes. Cramps. Muscle tension. Physical examination: skin is icteric, spider naevi, gynecomastia, ascites. Hepatosplenomegaly.
On ECG - bradycardia, decrease of voltage. The analysis of blood: Hb - 125 g/l, erythrocytes - 5,0*10¹², leucocytes - 11,6*109, stab neutrophils - 7%, segment. - 74%, eosinophiles - 1%, lymphocytes - 17%, monocytes - 1%, ESR - 15 mm/h. Bilirubin: the general - 55,0 mmol/L, direct - 45,0 mmol/L, indirect - 10,0 mmol/L. Albumine - 29,0 g/L, АLТ - 3,8 mmol/L/h, AST - 3,6 mmol/L/h. Protrombin index - 68%.
No 44:
1. Hepatic coma due to alcohol intoxication;
2. Infusional therapy, Hepasteril-A, Glutargin. Mannitol given by repeated bolus injections (0.5 g per kilogram of body weight over a period of 10 minutes). Intestinal lavage. Lactulose. Antibacterial therapy (neomycin sulphate 1 g) may also be used to reduce ammonia production by intestinal bacteria. Correction of pH, monitoring of blood glucose
SITUATIONAL TASK OF EMERGENCY 45
A man 60 years old has lost consciousness in the street. He was taken to hospital by ambulance. Objective: adynamia, skin is pale, cold sweat. Pulse - 30 beats/min, rhythmic. BP - 60/0 mm Hg. Auscultation: harsh breathing, rales are absent. Heart sounds are decreased and rhythmic. HR - 30 beats per min. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG:
No 45:
1. Acute Q-wave myocardial infarction of anterior-lateral wall of LV, complete AV-block
2. Sol. Atropini 0,1 % - 0,5 ml I/V, morphine 1% - 1ml I/V, oxygen inhalation, aspirin, heparin 5-10 thousand IU I/V, then 1000 IU/hour I/V drops 48-72 hours, dopamine I/V drops 2-4 mcg/kg/min, if not effective – prednisolone. Implantation of temporary pacemaker.
SITUATIONAL TASK OF EMERGENCY 46
The woman, 52 years old, worked in the summer in a kitchen garden. Suddenly, she felt a sting of an insect at the left hand. In 1 minute the edema of a hand appears. Through 5 minutes she lost consciousness. The doctor on a place determined: consciousness is absent, skin is pale. Pulse - 30 beats/min, rhythmic, thready on carotis arteries, on peripheral arteries pulse is absent, the arterial blood pressure - 60/0 mm hg, breathing ~12 per minute.
No 46:
1. Anaphylactic shock
2. Oxygen inhalation, adrenaline 0,1 % - 1 ml on 20 ml. NaCl 0,9% I/V, prednisolone 90 mg I/V, rehydration
SITUATIONAL TASK OF EMERGENCY 47
The man, 48 years old. In the anamnesis: smokes 30 years, essential hypertension - 10 years, obesity of 2 degrees. After physical exercise, he has sudden burning pain behind the chest with irradiation in the left hand, cold sticky sweat, nausea.
Objective: consciousness is clear, skin is pale, cold sweat. Pulse - 82 beats/min, rhythmic. BP - 140/90 mm Hg. Auscultation: vesicular respiration, rales are absent. Respiratory rate - 18 per minute. Heart sounds are decreased and rhythmic. Abdomen is soft and painless. Liver is not enlarged. Peripheral edema is absent. On ECG:
No 47:
1. Acute non Q-wave myocardial infarction of anterior-lateral wall of LV
2. Morphine 1% - 1ml I/V if pain persists, oxygen inhalation, aspirin (clopidogrel), heparin (fraxiparin, clexan), metoprolol (carvedilol); nitrates.
SITUATIONAL TASK OF EMERGENCY 48
The man of 30 years has suddenly lost consciousness.
Objectively: the consciousness is absent, skin is pale, pulse on carotid arteries is absent, breath is absent. On cardiomonitor:
No 48:
1. Ventricular fibrillation
2. Punch to the sternum region, closed massage of heart and artificial ventilation of lungs, electric cardioversion.
SITUATIONAL TASK OF EMERGENCY 49
The man, 48 years old. In the anamnesis: diabetes mellitus 20 years, essential hypertension - 20 years, obesity of 3 degrees, 2 years ago had Q-wave myocardial infarction of posterior wall of left ventricle.12 hours ago pressed substernal pain appeared. Patient not paid attention on it. Condition became worse. Suddenly, the man has breathlessness, cough.
Objective: orthopnea, acrocyanosis, respiratory rate - 34 per minute, muscles take part in respiration. Auscultation of lungs: moist rales of different intensity on all regions of lungs. Pulse rate - 98 beats per min, BP - 140/90 mm Hg. Abdomen is soft and painless. Liver is not increased. Peripheral edema is absent. On ECG:
No 49:
1. Repeated acute Q-wave myocardial infarction of anterior-lateral wall of LV, pulmonary edema.
2. Oxygen inhalation through 70% spirit (antifoamsilane), aspirin, morphine 1% - 1ml I/V, nitroglycerine 1% - 2ml in 200ml of 0.9% NaCl I/V drops, furosemide (lasix) 40-80 mg I/V, heparin.
SITUATIONAL TASK OF EMERGENCY 50
The man, 38 years old, suddenly after stress felt palpitation, breathlessness.
Objective: consciousness is clear, respiratory rate - 24 per minute. Auscultation of lungs: vesicular respiration, no rales. Heart sounds are arhythmic, pulse rate - 126 beats per min, BP - 180/90 mm Hg. Abdomen is soft and painless.
On electrocardiogram:
No 50:
1. Paroxism of atrial fibrillation
2. Sedatives, potassium drugs, if not effective - etacisin 50 mg sublingually. If not effective – amiodaron 5% - 6-9 ml (300-450 mg) in 100-150 ml 5% glucosae I/V in drops, heparin, aspirin.
SITUATIONAL TASK OF EMERGENCY 51
The patient 22 years old was hospitalized with complaints of weakness, cough with mucous-purulent sputum, sometimes with blood streak, rise in body temperature up to 38-390С, pain in the right half of the thorax, amplifying at cough. Percussion above lungs reveals pulmonary sound, on auscultation - vesicular breathing is weakened below scapular on the right side, in the same place – small bubble rales.
The condition became worse after staying in for 3 days. Dyspnea at rest, HR- 32 per minute. The right half of thorax lags behind during respiration act. In the lower part of the right half of the thorax vocal fremitus can’t be heard. Percussion: dull sound; auscultation of above the dull sound zone reveals sharply weakened respiration, breathing is absent in the lower part. The analysis of blood: leukocytes - 17,5 х 109/l, stab cells - 11 %, ESR-43 mm/hr.
No 51:
1. Community-acquired pneumonia of lower lobe of right lung, severe course, exudative pleurisy of right side, pulmonary insufficiency II degree
2. Thoracentesis or tube thoracostomy. Pleuritic pain can usually be managed with NSAIDS or other oral analgesics. Appropriate treatment involves starting antibiotics as soon as possible, preferably ≤ 8 h after presentation. β-lactam (cefpodoxime 200 mg po q 12 h; cefuroxime 500mg po q 12 h; amoxicillin 1 gq 8 h; amoxicillin/clavulanate875/125 mg q 12 h) plus A macrolide po or Antipneumococcal fluoroquinolone (alone) po; Azithromycin 500 mg IV q 24 hplusβ-lactam IV (cefotaxime 1 to2 g q 8 to 12 h; ceftriaxone 1g q 24 h). Supportive care includes fluids, antipyretics, analgesics, mucolytics (ambroxol) and for patients with hypoxemia – O2.
SITUATIONAL TASK OF EMERGENCY 52
The patient is hospitalized with attack of acute pain in the right lumbar area, body temperature 390С, fever, acute pain in the lower abdomen with irradiation to perineum. The BP 140/80 mm hg, pulse - 88 per minute, right kidney is painful during palpation. General urine analysis: Relative density - 1026, protein 1,2 g/L, er. - 25-27 in a field of vision, leukocytes 10-12 in a field of vision, epithelial - plenty squamous epithelium, salts – oxylates. Ultrasonic investigation of kidneys: echo structure is not homogenous, presence of multiple echo-contrast formation of 7-8 mm in the middle third of right ureter, absence of secretion of contrast from the right ureter.]
Determine the emergency
No 52:
1. Urolithiasis. Right side renal colic.
2. spasmolytics, diuretics, detoxication, antibiotics
SITUATIONAL TASK OF EMERGENCY 53
A 54-y.o. male patient who abused alcohol and had chronic viral hepatitis B complained of intensive heartburn. Suddenly he began profuse vomiting with fresh blood. On exam: pulse -108/min, BP - 90/60 mm Hg, icteric scleras and skin, ascitis, hepatosplenomegaly.
No 53:
1. Liver cirrhosis of mixed etiology, portal hypertension., esophageal varices, acute bleeding
2. Endoscopic band ligation or sclerotherapy, Blakemore-Sengstaken balloon tamponade, vasopressin i.v., octreotide i.v.
SITUATIONAL TASK OF EMERGENCY 54
A 49-aged male patient was admitted to the gastroenterology department with very severe abdominal pain predominantly in epigastrium with duration of 1 hour. Previously a duodenal ulcer with infrequent exacerbations was diagnosed. The abdominal pain became not so severe in a position on left side having drawn the legs. The abdomen on palpation is very painful, wooden belly. Tympanic sound while liver percussion. Liver dullness is not revealed. Passage of gases is absent.
No 54:
1. Duodenal peptic ulcer complicated with perforation into the peritoneal cavity
2. surgical treatment
SITUATIONAL TASK OF EMERGENCY 55
Male, 68 years old, complains on progressive weakness, tiredness, absence of appetite, weight loss, permanent independent of meals abdominal pain and discomfort, nausea, vomiting with “coffee ground”.
No 55:
1. Gastric carcinoma complicated with acute bleeding
2. Urgent endoscopy, surgical treatment
SITUATIONAL TASK OF EMERGENCY 56
A 60 year old patient complains of a acute pain in right hypochondrium during 36 hours, which appeared after fatty meal and alcohol intake. In anamnesis - chronic pains in the right hypochondrium. Objective: moderately obese, icteric sclera and skin. Body temperature 38,20 C. Phrenicus symptom is positive. Right hypochondrium is painful on palpation. Dimensions of liver are normal. Ultrasonograpy: presence of multiple echo-contrast formation of 5-8 mm in the gallbladder.
No 56:
1. Cholelithiasis, acute cholesystitis, obstructive jundise
2. surgical treatment – cholesystectomy
SITUATIONAL TASK OF EMERGENCY 57
Patient N, male, 48 years old, was receiving therapy with Actrapid and Lantus for 2 years due 2 type Diabetes mellitus and diabetic polyneuropathy of both lower extremeties. Daily dosage of Insulin was 42 U. He was admitted to hospital due to worsening of his state. The laboratory values of fasting glucose were following: 10,2 mmol/l, 9,2 mmol/l. HbA1c 10,5%. Daily dose of Insulin was increased to 46 U. In 2 days later patient injected morning dose of Insulin but then delayed his breakfast. Soon he complained of headache, weakness, tremor, sweating. Glucose value was 2,4 mmol/l.
No 57:
1. Hypoglicemia
2. I.v. 20-40 ml 40% glucose sol. if ineffectiveness repeat one more. after restoration of consciousness give a lot of sweets or food
SITUATIONAL TASK OF EMERGENCY 58
Patient 40 years old, complains on weakness, dizziness, bruises on skin, and gums, uterine bleedings. Anamnesis: symptoms appeared after suffering from tonsilitis 2 weeks ago. General condition is severe. Skin is pale with petechial skin rash. Peripheral lymph nodes are not increased, sternalgia and ossalgia are absent. Pulse 110/min, rhythmic, systolic murmur is heard over all points. Abdomen is soft, painless, liver and spleen are not palpable. Blood: erythrocytes 2.5x10*12/l, Hb 60 g/l, C.I 0.7, thrombocytes 15x10*9/l, segmented 70%, lymphocytes 25%, monocytes 5%, ESR 30mm/h. Myelogram: megakaryocytes are not surrounded by thrombocytes.
No 58:
1. Thrombocytopenic purpura
2. Glucocorticoids- prednisolone 1-2 mg/kg. If it’s no response - splenectomy (at 4-5 years old patient). Cytostatic therapy (azathyoprin, cyclophosphamide).
SITUATIONAL TASK OF EMERGENCY 59
Female patient, 52 years old, has been having on Grave’s disease during 3 years at the background of CAD and irregularly taking of mercazolile. On hospitalization she experienced palpitation, dyspnea, marked fatigue, extended abdominal pain, nausea, vomiting and diarrhea. On examination: T – 39o, pulse rate 180 bpm, BP 85/40 mm Hg. Patient is agitated, skin is wet, in lower parts of lungs wheezing is heard.
No 59:
1. Thyrotoxic crisis.
2. in pre-hospital i.v. 400ml 5% glucose, in hospital - monitoring of thyroid hormones, electrolyte balance in serum and i.v. infusion of vasopressors, cardiac glycosides, glucocorticosteroids and 10% 100ml sodium iodide every 8 hours after thyrostatic medicines ( mercasolil per oral)
SITUATIONAL TASK OF EMERGENCY 60
Patient 78 years old, complains of sudden breathlessness, discomfort behind a chest, feeling of palpitation, dizziness. Objectively: edemas of legs, HR 140 per minute, pulse is rhythmical, BP 70/30 mm Hg. Auscultation: decreased vesicular breathing, no rales, respiratory rate 40 per minute. A varicose phlebectasia of the lower extremities. ECG: sinus rhythm, acute coronary pathology is absent. Ultrasonography of veins of the lower extremities revealed thrombus masses. Determine the emergency
Provide first aid
No 60:
1. Varicose phlebectasia of the lower extremities, pulmonary artery tromboembolism.
2. Oxygenotherapy, trachea intubation. Anticoagulant (Sol. Heparin 10000 e., further on 1000 е./1 hour). Antiaggregants (Tab. Aspirin 325 mg and Tab. Clopidogrel 300 mg) Thrombolitics: Sol. Alteplase 100 mg within 6 hours. Crystalloids, Dofamin or Dobutamin for maintenance perfusion organs and tissues.
SITUATIONAL TASK OF EMERGENCY 61
Patient 85 years old was hospitalized in intensive care unit with acute Q-wave anteriol and lateral wall myocardial infarction 5 days ago. Suddenly he had felt a strong pain in a chest, had become covered clammy sweat, then has lost consciousness.
Objectively: unconscious state, pale skin, spontaneous respiration is absent, pupils are dilated and pulse on carotid artery is absent, jugular veins are distended. On cardiomonitor: a spontaneous ventricle rhythm, frequency 10-20 per minute. Echocardiography: the significant amount of a liquid in a cavity of a pericardium and visualized defect of lateral wall of left ventricle.
No 61:
1. IHD: acute Q-wave anteriol and lateral myocardial infarction, rupture of a lateral wall left ventricle with a pericardium tamponade.
2. Rendering of the urgent help is carried out by principles of АВС reanimation, a puncture of a pericardium, emergency operative treatment on wound closure defect of a lateral wall left ventricle with drainage of cavity of a pericardium.
SITUATIONAL TASK OF EMERGENCY 62
A 44-year-old alcohol abuse male patient is brought to the emergency room complaining of severe abdominal pain of 6-8 hours duration. The pain is in the epigastrium radiating to the back and is accompanied by nausea. These symptoms were start after taking a fatty food with spirits. The patient had vomited twice prior to coming to the emergency room. Clinical examination revealed that the man was anxious, with a regular pulse rate of 100/ min, blood pressure of 100/68 mm Hg, and body temperature 38,1 °C.
No 62.
1. Acute pancreatitis
2. Stop alcohol, narcotic analgesics, octreotide i.v., spasmolitics i.m., i.v. solutions (chlorane, sodium bikarbonate), wide-spectrum antibiotics, pancreatic enzymes p.o.
SITUATIONAL TASK OF EMERGENCY 63
A 40-year-old man with previously treated urinary tract infection by sulfanilamide complains of fever 38.5оС, chill, significant weakness, pain in the throat. A patient examination revealed an ulcerative-necrotic tonsillitis, lymphadenopathy. CBC: RBC 3,7х10 12/L, Hb 120 g/L, WBC – 0,70•109/L with 0% eosinophils, 1% stabs, 2% segmented neutrophils, 94 % lymphocytes, 3% monocytes, ESR – 22 mm/h.
No 63
1. Acute immune agranulocytosis, ulcerative-necrotic tonsillitis
2. Hospitalization to aseptic room, antibiotics i.v. (cephalosporin 2,3 generation, vancomycin, amikacin), neomycin p.o, Sodium nucleinate p\o
SITUATIONAL TASK OF EMERGENCY 64
The 54-year-old patient was administered to the hospital due to increase BP until 180/110 mm Hg, not respond to standard antihypertensive treatment. Suddenly he complains of strong acute pain in the right lower abdomen with irradiation to perineum. The Pasternatsky’ symptom is expressed on the right side.
CBC: L-8,2*109/l, steb-8% , ESR 28 mm/h. Uranalysis: specific gravity of urine 1014, protein- 0.132 g/l, WBC - 20-30 in f/v, fresh RBC- 15-20 in f/v, salts – oxylates. Ultrasonic investigation of kidneys: echo structure is not homogenous, presence of multiple echo-contrast formation of 7-8 mm in the middle third of right ureter.
No 64
1. Urolithiasis. Pyelonephritis. Right side renal colic.
2. spasmolytics, diuretics, hypotensive, detoxication, antibiotics
SITUATIONAL TASK OF EMERGENCY 65
The 46 years-old patient was delivered by ambulance to the hospital in the comatose state.
Objectively: severe state, consciousness is confused, answers to questions inadequately, dry lips and tongue, acetone smell from mouth. Skin is dry, pale, cold, the turgor of skin is decreased. Noisy breathing (Kussmaul), respiratory rate 16 per minute. The pulse is rhythmic 120 per minute. Body temperature - 36,40C. The eyeballs are soft. Corneal and knee reflexes are depressed. Blood glucose - 20.5 mmol/l.
No 65
1. DM ,Ketoacidosis
2. Definition of glicemia level & electrolytes balance, infusion of short active insulin, rehydration, correct electrolytes and ph imbalance.
SITUATIONAL TASK OF EMERGENCY 66
A 38-year-old woman is seriously ill. She complains of frequent paroxysms of expiratory dyspnea. The last paroxysm lasts over 12 hours and fails to respond to theophylline. During examination: position is forced, orthopnea. The skin is pale gray, moist. Respiratory rate of 33/min. On auscultation, breath sounds are absent over some areas. Pulse rate 100 beats per min. BP – 130/90 mm Hg.
No 66
1. Bronchial asthma, status asthmaticus
2. O2, i.v. glycocorticoids – prednisolons, dexametason, hydrocortison. Nebulaizer inhalation of sympatomimetics, corticosteroides.
SITUATIONAL TASK OF EMERGENCY 67
A 38-year-old patient was hospitalized with complains of increased temperature till 39 0С, cough, stabbing pain in the chest, mainly in the left.
Objectively – mild diffuse cyanosis, left half of thorax lags behind during respiration. Auscultation revealed bronchial respiration lower the angle of left scapula with moist small-bubble rales. In blood analysis, Er - 4,12 х 1012/l, L - 12,2 х 109/l, ESR - 32 mm/hour.
No 67
1. Left sided lower lobe pneumonia
2. Thoracentesis or tube thoracostomy. Pleuritic pain can usually be managed with NSAIDS or other oral analgesics. Appropriate treatment involves starting antibiotics as soon as possible, preferably ≤ 8 h after presentation. β-lactam (cefpodoxime 200 mg po q 12 h; cefuroxime 500mg po q 12 h; amoxicillin 1 gq 8 h; amoxicillin/clavulanate875/125 mg q 12 h) plus A macrolide po or Antipneumococcal fluoroquinolone (alone) po; Azithromycin 500 mg IV q 24 hplusβ-lactam IV (cefotaxime 1 to2 g q 8 to 12 h; ceftriaxone 1g q 24 h). Supportive care includes fluids, antipyretics, analgesics, mucolytics (ambroxol) and for patients with hypoxemia – O2.
SITUATIONAL TASK OF EMERGENCY 68
A 62 y.o. patient complains of pain in right half of thorax near breathing, shortness of breath, dry cough. 10 day ago he fall in the street and strike right side of the chest. Objectively: patient lies on left side. A right half of thorax falls behind of breathing. Crepitation and tenderness of IІ-ІІІ ribs at right. Inspection of the lungs: dull sound and significant weakened breathing lower the III rib at right. On the X-ray: level of fluid on the right in the III intercostal space, fractures of the IІ-ІІІ ribs. Analyze of pleural fluid revealed blood.
No 68
1. Right sided posttraumatic haemothorax
2. Punction and drainage of pleural cavity
SITUATIONAL TASK OF EMERGENCY 69
The woman, 28 years old, after an injection of 0,5% solution of Novocain for the local anesthesia she suddenly lost consciousness. Objectively: consciousness is absent, skin is pale, breathing is ~12 per minute, superficial. Pulse on carotis arteries - 30 beats/min, rhythmic, thready, on peripheral arteries pulse is absent, the arterial blood pressure - 60/0 mm hg.
No 69:
1. Anaphylactic shock
2. Oxygen inhalation, adrenaline 0,1 % - 1 ml on 20 ml. Rehydration - NaCl 0,9% I/V, prednisolone 90 mg I/V.
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(TB)
№ 1
The man of 30 years, the smoker, works on a metallurgical works, he is complained of cough with discharge of sputum, increase of body t° up to 38,6°, dyspnea, weakness. In the anamnesis – Botkin's disease, eczema. On the roentgenogram in the superior lobe of the left lung is the certain shadow of 3х2,5 sm with dim contours and a path to a root of the lung. Auscultative vesicular respiration is in the lungs. What is the most possible diagnosis?
1. Infiltrative tuberculosis
№ 2
The man of 40 years, suffer with cough about three years. Two months ago he was released from places of imprisonment. He sharply fall ill, cough was amplified, dyspnea, increase of body t° up to 38,0° was appeared. He was hospitalized in a hospital with suspicion on pneumonia. On the roentgenogram in the superior parts of lungs were single, small, focal shadows, weak-intensive, with dim contours. What is the most possible diagnosis?
2. Disseminated tuberculosis
№ 3
The patient A. of 19 years old suffers with bronchial asthma. At radiological examination in the 4-nd segment of the right lung the site of blackening up to 3 sm in diameter of average intensity, with clear equal contours and presence of small intensive focal shadows in surrounding lung’s tissue is revealed. It is determined box percussion sound above the lower departments of lungs; here it is listened weakened vesicular respiration and individual dry rales. The analysis of blood within the limits of norm, Mantoux’ test with 2ТЕ – papule was 20 mm. Put the most probable diagnosis.
3. Tuberculoma of the 2-nd segment of the right lung
№ 4
In patient Z. of 27 years old at policlinic examination are revealed changes in lungs by a fluorography method. Complaints are absent. Objectively pathology it is not revealed. In blood: СОЭ – 18 mm at one o'clock. Mantoux’ test with 2ТЕ – papule was 19 mm. Roentganologically: in the 2-nd segment of the left lung the site of blackening of average intensity with equal clear contours, with presence of a crescent lucid interval in area of draining bronchus is determined. Put the most probable diagnosis.
4. Tuberculoma of the 2-nd segment of the right lung in a phase of disintegration
№ 5
In patient С. of 22 years old for the first time at policlinic examination small intensive focal shadows in the 1-st and 2-nd segments of the right lung with indistinct contours are revealed by a fluorography method. It was rose body temperature in the evening up to 37,1-37,2º. Objectively without a pathology. The analysis of blood within the limits of norm. МBТ in sputa are undetected. Mantoux’ test with 2TE – papule was 11 mm. Put the most probable diagnosis.
5. Focal tuberculosis of the 1-st and 2-nd segments of the right lung, a phase of infiltration, МBТ–
№ 6
The man of 32 years has addressed with complaints to indisposition, weakness and cough. At objective examination special changes it is not revealed. It has been carried out roentgenography of a chest cavity in a direct projection. On an apex of the right pulmonis the group of small focal shadows of small intensity with indistinct rough contours is revealed. What diagnosis you can establish?
6. Focal tuberculosis of the left lung
№ 7
The man of 32 years has addressed with complaints to indisposition, weakness and cough. At objective examination special changes it is not revealed. It has been carried out roentgenography of a chest cavity in a direct projection. On an apex of the right pulmonis the group of small focal shadows of small intensity with indistinct rough contours is revealed. What diagnosis you can establish?
7. Focal tuberculosis of the 2-nd segment of the right lung in a phase of disintegration, МBТ –
№ 8
Patient О. of 19 years had acute disease when the body temperature up to 39 has increased, dyspnea, dry cough has appeared. She had contact to the patient with the open form of tuberculosis. It is expressed cyanosis of lips. Rales in lungs are not listened. In blood: leukocytes – 12.0х109, stab neutrophyles – 10 %, monocytes – 10 %, ESR – 45 mm at one o'clock. МBТ are not found out. Mantoux’ test with 2ТЕ – papule was 8 mm. Roentgenologically: on all extent of lung fields, it is more in super-cortical departments, small intensive, small focal shadows with indistinct contours are determined. Put the most probable diagnosis
8. Miliary tuberculosis, МBТ – –
№ 9
In patient А., 37 years, addressed to the doctor with complaints to cough with a small amount of sputum and an increasing dyspnea, roentgenologically have revealed focal shadows in lungs of the different form of size and the intensity, located symmetrically with two sides, mainly in the superior departments on a background of pneumosclerosis. Individual scattered dry rales in lungs are listened. In blood: leukocytes – 9.4х10 9/l, ESR – 28 mm at one o'clock, МBТ are not found out by all methods. Mantoux’ test with 2 TE – papule was 15 mm. Put the most probable diagnosis
9. Disseminated tuberculosis of lungs in a phase of infiltration, МBТ –
№ 10
Patient Z., 18 years, has addressed to the doctor with complaints on rise of a body temperature till 38-39º, pain in a breast amplifying at a deep breath, an increasing dyspnea. The brother has the open form of tuberculosis. It is determined shortening passing in dullness in the lower department percussively above the left lung. Breath above the left lung is sharply weakened. In blood: leukocytes – 10.2х10 9/l, ESR – 32 mm at one o'clock. Roentgenologically: the left lung field homogeneously is darkened, more intensively in a lower-lateral department. Heart is displaced to the left. Mantoux’ test with 2TE – papule was 19 mm. Put the most probable diagnosis
10. Right-side exudative pleurisy of tubercular etiology
№ 11
Patient B., 37 years, has addressed to the doctor with complaints on rising of body temperature up to 38-38,5º, cough with small amount of sputum coctum, increasing dyspnea, weakness, sweating, bad appetite. He suffers by alcoholism. He was not examined 5 years by roentgenologically. He is skeletizated. The right half of thorax is impressed; it is behind in the act of breath. It is determined acute shortened of percussion sound above a right lung. It is rough respiration here. At internal edge of scapula on the right in its upper one third the small amount of different moist rales is listened. In blood: leukocytes – 9.0х10 9/l, ESR – 28 mm at one o'clock. МBТ are found out in sputum by all methods. Put the most probable diagnosis
11. Fibrocavernous tuberculosis of the lungs, МBТ + +
№ 12
In the patient of 36 years were complaints on the common weakness, subfebrile temperature, bloody spitum. It is marked blunting of a percussion sound on an apex of the right pulmonis at percussion. Auscultative – on an apex of the right pulmonis there were single small bubbling rales on a background of weakened vesicular respiration. Roentgenologically: there is no intensive no homogeneous blackening from an apex to the ІІІ rib due to the confluent foci and infiltration, on which background at a level of the ІІ rib a site of disintegration was d-1,5х1,5 sm. Focal shadows of weak intensity were at the left on the level of the III rib. It is diagnosed infiltrative tuberculosis of the upper lobe of the right lung. In what phase there is a specific process?
12. Disintegration and bronchogenic dissemination
№ 13
Patient L. of 45 years has complaints to dry cough, blood sputum, dyspnea at physical load, the common weakness, rise of body temperature. At percussion to the right from an apex to the lower corner of the scapula and under clavicle are dullness. On this site of breath is bronchovesicular, near the upper corner of scapula are moist mild-bubbling rales. On the survey roentgenogram of a thorax from above in the IV rib is intensive not homogeneous blackening with clear lower border; in the 2-nd intercost is circular lumen. What is the clinical diagnosis?
13. Infiltrative tuberculosis of the superior lobe of the left lung, a phase of disintegration № 14
In the patient of 25 years at preventive fluorographic examination shadows of 4-10 mm are revealed in the 1st – 2nd segments of the right lung, in irregular-shaped diameter, small intensity without clear contours. Reaction to Mantoux’ test with 2 TU – papule is 7мм. The analysis of blood: leukocytes – 9,9 • 109 g/l, ESR – 26 mm/h. What is the most probable diagnosis in your opinion?
14. Focal tuberculosis
№ 15
The patient of 64 years suffers with diabetes 5 years. At the next inspection on the roentgenogram of thorax organs in S-6 of the left lung the irregular-shaped shadow in the size of 4х5 sm with lumen in the center is revealed. Contours of shadow are indistinct, intensity is milled. In the left root is calcinate. The analysis of blood: leukocytes – 11,5•109 g/l, ESR – 55 mm/h. Reaction to Mantoux’ test with 2 TU – papule is 5 mm. Specify the most possible diagnosis.
15. Infiltrative tuberculosis with disintegration
№ 16
The patient of 42 years was taking prednisolone more than a year on occasion of polyarthritis. Three months ago cough has appeared at him, he began to lose weight of body (on 8 kg.), the body temperature up to 38,5ºC. On the CT of lungs from two sides in the upper departments were focal shadows of small and middle intensity without clear contours, at the right focus in size of 3,5х4 sm with lumen. The analysis of blood: leukocytes – 11,0 • 109 g/l, ESR – 45 mm/h. Mantoux’ test with 2 TU – papule was 6 mm. What is the most possible diagnosis?
16. Disseminated tuberculosis
№ 17
In the patient of 37 years at the preventive examination on fluorogram of thorax the shadow of 3х3,5 sm of the round form in S-6 of the left lung with clear contours of heterogeneous structure, medially – lumen as a sickle is revealed. The analysis of blood: leukocytes – 10,5 • 109 g/l, ESR – 30 mm/h. Mantoux’ test with 2 TU – infiltrate was 13 mm. Specify the most possible diagnosis.
17. Tuberculoma
№ 18
The patient of 30 years has arrived to a hospital from places of imprisonment where from his words he was treated on occasion of tuberculosis during 2 months. He had complaints to cough after dream, an unstable body temperature. On the roentgenogram of lungs at the left in the 1st – 2nd segments there is circular shadow in the size of 3х3 sm, a thickness of walls are 2-3 mm, an internal contour is clear, external is dim, the single foci are around the cavity. The analysis of blood: leukocytes – 9,0 • 109 g/l, erythrocytes – 6 %, stab neutrophils – 10 %, segmented neutrophils – 60 %, lymphocytes – 19 %, monocytes - 5 %, ESR – 22 mm/h. Mantoux’ test with 2 TU – papule is 7 mm. Specify the most possible diagnosis.
18. Fibrocavernous tuberculosis
№ 19
The patient of 40 years is getting registered in tubercular dispensary on occasion of chronic alcoholism. He didn’t examine more than 2 years. On the roentgenogram of lungs at the left in the upper department the cavity of leguminous form by the size of 4х4,5 sm, thickness of a wall is 4 mm, intensity is high, an internal contour is clear, external – dim is determined. Around of a cavity and in the lower department a plenty of the foci which are joined by places in focuses. In the analysis of sputum are found МBТ 15-20 in sight. What is clinical form of tuberculosis at this patient?
19. Fibrocavernous
№ 20
The patient of 28 years is got registered in tubercular dispensary during 2 years. The basic course of treatment in a hospital has finished one year ago therefore has come improvement. On the survey roentgenogram of lungs at the right the superior lobe is reduced in volume, blackened out up to high intensity, it has heterogenous structure, a root and mediastinum were displaced to the right. In the root is calcinate. In the inoculation of sputum – growth of МBТ, there were 2 colonies. What is most possible form of tuberculosis in this patient?
20. Cirrhotic tuberculosis
№ 21
The young man of 18 years, the student, he is got registered in tubercular dispensary 6 months ago on occasion of turn of tubercular test. He did not accept a preventive treatment. He was ill two weeks ago, the pain in a thorax has appeared, dry cough, dyspnea, the temperature up to 38ºС has raised. At the examination the right half of thorax is behind at breathing. On the roentgenogram of lungs a zone of blackening is from the ІІІ rib to a diaphragm of high intensity, the homogeneous, upper border is in a form of slanting shadow, the lower – is joined with a diaphragm and soft tissues. The analysis of blood: leukocytes – 12,0х109 g/l, ESR – 50 mm/h. Mantoux’ test with 2 TU – papule was 18 mm. What is the most possible diagnosis?
21. Exudative pleurisy
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infectious
| № of the tasks | Diagnosis | № of the tasks | Diagnosis
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1 | Cholera | 31 | Trichinosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 2 | Shigellosis | 32 | Marseilles fever | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 3 | Enteroviral diarrhea | 33 | Viral hepatitis B (coma) | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 4 | Yersiniosis | 34 | Pseudotuberculosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 5 | Salmonellosis | 35 | Yiersiniosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 6 | Food – poisoning intoxication | 36 | Taeniarinhosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 7 | Typhoid fever | 37 | Enterobiosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 8 | Botulism | 38 | Meningococcal infection Nasopharingitis Meningococcemia | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 9 | Typhus fever | 39 | Leptospirosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 10 | Brill's disease | 40 | Tetanus | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 11 | Q - fever | 41 | Typhus fever | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 12 | Tick - born encephalitis | 42 | Strongyloidosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 13 | Leptospirosis | 43 | Brucellosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 14 | Diphtheria | 44 | HIV - infection | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 15 | Tertean malaria (late relaps) | 45 | Shigellosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 16 | Anthrax | 46 | Typhoid fever | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 17 | Erysipelas | 47 | Anthrax | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 18 | Tularemia | 48 | Brucellosis | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 19 | Brucellesis | 49 | Cholera | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 20 | Plague | 50 | Hemorragic fever with a renal syndrome | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 21 | Influenza | 51 | Viral hepatitis B | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 22 | Meningococcal infection | 52 | Viral hepatitis B | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 23 | Hemorragic fever with a renal syndrome (HFRS) | 53 | Viral hepatitis B. Koma
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 24 | Tetanus | 54 | Viral hepatitis B, D. Koma | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 25 | Infectious mononucleosis (glandula fever) | 55 | Viral hepatitis A | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 26 | HIV - infection | 56 | HIV - infection | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 27 | Viral hepatitis A | 57 | HIV - infection | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 28 | Viral hepatitis B | 58 | HIV - infection | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 29 | Adenoviral infection | 59 | HIV - infection | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 30 | Tropical malaria | 60 | HIV - infection AIDS – associated diseases. Pneumocystic pneumonia.
|
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