Situational Task # 1
Male patient, 52 year old, complains of sudden episodes of dizziness, weakness, presyncope and syncope conditions. Objective: BP 100/60 mm Hg, heart rate 40 bpm. (ECG А-3, Biochemical investigation - 6.9, Coagulogram – 4.1, X-ray 18)
Coagulogram – 4.1 ?
X-ray 18 present of pacemaker,enlargement of LV
diagnosis : CHD: complete heart block.
Situational Task # 2
A 60 year old man, previously practically healthy, had sudden feeling of fear, restlessness and palpitation. BP-160/90 mm Hg, heart rate 150 bpm. (ECG А-29, Biochemical investigation - 6.9, Coagulogram - 4.1, X-ray 23)
- Normal axis
- PQ=-, QRS=0.08 norm, QT= 0.28 norm,
- P=-, Q=no deep, R=13mm voltage is kept,
Situational Task # 3
A 52 year old female patient had sudden appearance of pain in the right lateral part of abdomen with irradiation to the inguinal region, nausea, vomiting and frequent urination. (Urinalysis - 1, USI – 7, USI – 79, X-ray 16)
Evaluate instrumental and laboratory data
Urinalysis – 1 presence of macrohematuria ( red color and fresh erythrocytes), urates in quantity. Turbid urine , it can be renal colic
USI – 7 , USI – 79 present of echogenenic substance , X-ray 16 present of stones
diagnosis : Urolithiasis. Renal colic.
Situational Task # 4
A 46 year old male patient had sudden dyspnea and acute right-sided chest pain when he stood up from the bed. 2 days ago he was operated for paraproctitis. Objective: diffuse cyanosis, tachypnea up to 40 per minute, cough. HR -120 bpm. BP-85/50 mm Hg. Swelling of neck veins. (Coagulogram - 4.1, ECG Г-14, X-ray 14, CT 5)
Evaluate instrumental and laboratory data
Coagulogram – 4.1 ?
ECG Г-14 hypertrophy of right atrium cor pulmonale hypertrophy of right ventricular
X-ray 14 dilation of bronchus..present of irregular homogenous shadow at the bronchus- trombus(maybe i think ),
CT 5 thrombus at bronhi
diagnosis :Pulmonary thromboembolism.
Situational Task # 5
A 34 year old female with known rheumatic mitral valve stenosis had sudden weakness and palpitation. Pulse is arrhythmic, BP-110/70 mm Hg. (Blood biochemistry - 6.17, ECG А-29, X-ray — 34, MRI 5)
Evaluate instrumental and laboratory data
Blood biochemistry - 6.17Rheumotest positive
ñ Diagnosis = Acute Rheumatic Fever
ñ Fibrinogen 4-5 = 1st degree
ñ CRP + = 1st degree
ñ Seromucoid <0.3 = 1st degree
ñ , ECG А-29 Non sinus (no P wave) Regular rhythm HR=136 (tachycardia)
ñ Normal axis
ñ PQ=-, QRS=0.08 norm, QT= 0.28 norm,
ñ P=-, Q=no deep, R=13mm voltage is kept,
ñ ST segment=normal Conclusion= artrial fibrillation
X-ray — 34 absent of AV junction angle.mitral configuration of heart.??
MRI 5
diagnosis :Rheumatic heart disease. Mitral valve stenosis. Paroxysmal atrial fibrillation.
Situational Task # 6
Male patient, 60 year old, had sudden feeling of severe weakness, palpitation and dyspnoea. Objective: paleness, acrocyanosis. BP - 70/40 mm Hg. Pulse is very weak, HR - 190 bpm. (Biochemical investigation - 6.4, ECG Б-5, X-ray 22)
Evaluate instrumental and laboratory data
diagnosis :CHD sustained ventricular tachycardia.
Situational Task # 7
Female postgraduate student, 24 year old, complains of weakness, prolonged dull pain in heart region, palpitation, which occurred 10 days after acute respiratory viral infection. On investigation muffled heart tones, HR - 100 bpm. BP - 110/70 mm Hg. (Blood biochemistry - 6.17, CBC - 3.1, ECG A-2)
Evaluate instrumental and laboratory data
ñ Diagnosis = Acute Rheumatic Fever
ñ Fibrinogen 4-5 = 1st degree
ñ CRP + = 1st degree
ñ Seromucoid <0.3 = 1st degree
diagnosis :Acute myocarditis.
Situational Task # 8
An ambulance was called to a 58 year old bank director. He complains on more than 30 minutes duration severe retrosternal pain without any relief after repeated nitroglycerine tablets intake. He had the similar but weaker pain episodes on physical exertion, which disappeared after short rest. HR-107 bpm. BP-150/80 mm Hg. (ECG А-28, Blood biochemistry 6.10, X-ray 13)
Evaluate instrumental and laboratory data
High AST , High Total CK and CK-MB suggests myocardial infarction
Situational Task # 9
A 52 year old male patient called for an ambulance. He had severe squeezing retrosternal pain, which appeared more than 1 hour ago without any obvious causes and didn't relieve after repeated nitroglycerine tablets intake. HR-70 bpm. BP-110/80 mm Hg. (ECG В-22, Blood biochemistry 6.11, X-ray 24, CT 4)
Evaluate instrumental and laboratory data
#ecg b 22- MI post-diaphagramal localization
#biochem 6.11 -acute MI
# xray 24 ?? # ct 4 ???
diagnosis :CHD: acute inferior myocardial infarction.
Situational Task # 10
A 64 year old male patient suddenly has lost consciousness by the road side. Thread-like pulse and no BP were determined. (ECG А-16, Blood biochemistry 6.12, X-ray 21, MRI 4)
Evaluate instrumental and laboratory data
Situational Task # 11
A 28 year old female patient had relapsing nasal bleeding. The presence of multiple petechial hemorrhages were revealed on the skin of abdomen and thighs. (CBC - 4.3, Blood biochemistry 6.13)
Evaluate instrumental and laboratory data
#cbc 4.3 :Conclusion:decrease RBC,HB,platlet
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Idiopathic thrombocytopenic purpura
#biochem 6.13 ?
diagnosis :Idiopathic thrombocytopenic purpura (Verlgof disease).
Situational Task # 12
35 year old male, previously practically healthy, after a severe emotional stress had experienced severe headache, internal tremor, tension and feeling of fear. HR 94 bpm. BP-190/100 mm Hg. (ECG В-9, Blood biochemistry 6.9)
Evaluate instrumental and laboratory data
#ecg b 9 : EAH deviated to the left.LV hypertrophy
#biochem 6.9 :Possibility : may b obstructive jaundice or cholestatic process in liver (biliary liver cirrhosis) , bcoz hypercholesterolemia.
Diagnosis :Essential hypertension, hypertensive urgency.
Situational Task # 13
A 53 year old male patient with established chronic glomerulonephritis has nausea, vomiting, insomnia and skin itching. HR - 60 bpm. BP - 190/120 mm Hg. (Renal function test - 9, urinalysis - 5, ECG В-12)
Evaluate instrumental and laboratory data
zimnitsky Conclusion:
Decreased amount of excreted urine (comparing with taken liquid) is typical for edema, nocturia : deviation between specific gravity in urine portion smaller than 10 indicate disordered concentrative f(x).
Such analysis can be in nephritic syndrome.
Urinalysis by Nechiporenko
Conclusion:
Increased RBC indicate Glomerulonephritis.
Reberg test Conclusion:
Decreased glomerular filtration and percentage of reabsorbed water, increased residual nitrogen,urea and Creatinine indicate Renal failure.
#urine analysis 5--> Possibility : proteinuria, microhematuria , cylinduria ,it can be glomerulonephritis
#ecg B12EAH dev to the left.hyperkalemia,hypertrophy LV
diagnosis :Chronic glomerulonephritis. CRF III stage.
Situational Task # 14
A 32 year old male patient with diabetes mellitus has irritation, aggressiveness, tremor of hands and sweating in the evening with development in 20-25 minutes convulsions, paleness and unconscious condition. (Blood biochemistry - 6.7, ECG B-9)
Evaluate instrumental and laboratory data
Situational Task # 15
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. (Functional liver test - 11, USI – 3, X-ray 2, MRI 2)
Evaluate instrumental and laboratory data
Dysproteinemia with increase globulin Beta n Gamma, increase moderately of AST n ALT indicates CHRONIC HEPATITIS.
diagnosis :Cholelithiasis. Gallstone colic.
Situational Task No#16
A 60 year old male surgeon complains of palpitations. He is heavy smoker, does many operations, and has many night duties. Objectively: HR 70 bpm, BP 140/90 mm Hg. (Biochemical investigation - 6.4, ECG А-21, radio 2)
Evaluate instrumental and laboratory data
Situational Task # 17
Male patient, 59 year old, complains of acute severe squeezing retrosternal pain during more than 40 minutes. He had stable angina pectoris last 5 years. HR-74 per min. BP-120/80 mm Hg. (ECG Д-28, Blood biochemistry 6.10, X-ray 19)
Evaluate instrumental and laboratory data
# ECG Д-28-MI subacute stage transmural affecting septum apex lateral wall
#biochem 6.10 -Hypercholesterolaemia, High level of LDL, Low level of HDL, High level of tryglicerides suggests background of atherosclerosis.
High AST , High Total CK and CK-MB suggests myocardial infarction
Conclusion: Myocardial Infarction.
#xray 19 ??sticture of vessel.maybe due to stenosis
diagnosis :CHD: acute antero-lateral Q-wave myocardial infarction.
Situational Task # 18
A 34 year old female complains of dyspnoea, cough with foamy sputum containing blood streaks. Objective: orthopnea, acrocyanosis, on auscultation massive moist rales over practically all lungs surface. SI is weakened with following decrescent systolic murmur and diastolic murmur after opening snap. S2 is accentuated. HR is irregular ~ 100 bpm, BP - 80/50 mm Hg. (Blood biochemistry - 6.18, roentgenogram - 35, ECG А-13, MRI 3, CT 3)
Evaluate instrumental and laboratory data
Diagnosis = acute Rheumatic Fever
Fibrinogen 5-6 = 2nd degree
CRP +++ = 3rd degree
diagnosis :Rheumatic heart disease. Combined mitral valve disease (mitral valve stenosis, mitral valve insufficiency). Atrial fibrillation. Pulmonary edema.
Male patient 64 year old, called for an ambulance because he had severe dizziness and weakness. Body temperature - 37.6º С. Enlarged lymph nodes were discovered 2 years ago with subsequent slow growth predominantly of neck, axillary, inguinal lymph nodes. Patient's general condition previously was stable. (CBC – 2.4, X-ray 9, CT 2)
Evaluate instrumental and laboratory data
diagnosis :Chronic lymphocytic leukemia. Autoimmune hemolytic anemia.
Situational Task # 20
A 30 year old female complains of fever, recurrent nasal bleeding and severe weakness during last 3 days. Lymphadenopathia, necrotizing tonsillitis were revealed. (CBC - 2.6, myelogram — 5.3, X-ray 12)
Evaluate instrumental and laboratory data
increase Leuk(leukocytosis)., blasts cel
increase stabs,ESR-inflammatory process
Situational Task # 21
Female patient, 24 years old, had increased body temperature up to 39º С for a long time, polyarthralgia, weakness, edema beneath eyes. Objectively butterfly-like facial rush, weakened breath and percussion sound over lowest part of right lung. (urinalysis - 14, Blood biochemistry - 6.19, X-ray - 10)
Evaluate instrumental and laboratory data
Leukocyturia
Diagnosis = Acute Rheumatic Fever
Fibrinogen 5-6 = 2nd degree
CRP +++ = 3rd degree
Situational Task # 22
Previously practically healthy mechanic, 40 year old, complains of cough, weakness, fever with increased body temperature up to 39º. On auscultation weakened breath over the upper part of right lung, on percussion dull sound over the same region. (CBC - 3.1, blood biochemistry - 6.16, sputum analysis - 5, X-ray – 20)
Evaluate instrumental and laboratory data
1. Mucopurulent-----chronic bronchitis, TB
2. Leukocytes increase-----inflammatory
3. Erythrocyte increase----- acute lobar pneumonia, congestion in lesser circulation, lung infarction
4. Alveolar cell increase------pneumonia
5. Bacteria+---- cocci
Situational Task # 23
Female patient, 55 years old, complains of general weakness, dyspnoea, dizziness, unsteady step (ataxia), bad appetite, gastric pain, diarrhea. In anamnesis: suffered from gastritis type A for 15 years. Objective: moderate severe condition, pale subicteric skin. Lymph nodes are normal. Heart tones are decreased, soft systolic murmur on all points of auscultation. BP-100/60 mm Hg. Pulse - 100 bpm, rhythmic. Tongue is bright red color, smooth and with fissures. Tenderness in epigastric region. Liver enlarged for 2 cm, palpation of lower border is painless. Borders of spleen are palpable. (CBC - 1.2, liver functional test – 12)
Evaluate instrumental and laboratory data
Conclusion= B12 deficiency anemia
# liver fx test 12 - Increase indirect bilirubin, increase amount of stercobilin indicate HEMOLYTIC JAUNDICE.
Dysproteinemia with increase more in globulin B n Gamma indicate CHRONIC HEPATITIS
Slightly decrease total cholesterol may indicate hepatic insufficiency.
Diagnosis :Megaloblastic anemia.
Situational Task # 24
Male patient, 36 years old, complains of fever, palpitation, general severe weakness. Lymphadenopathia, necrotizing tonsillitis were revealed. (CBC - 2.1.2, myelogram — 5.3, X-ray 11)
Evaluate instrumental and laboratory data
Situational Task # 25
A 50 year old male patient complains on weakness, disseminated bone pain, progressive weight loss, polyarthralgia, subfebrile temperature. (CBC - 2.5, urinalysis – 66, blood biochemistry - 6.2, myelogram – 5.4, X-ray 3)
Evaluate instrumental and laboratory data
Situational Task # 26
An acute leukemia 22 age old female patient was undergone cytostatic therapy with daunorubomicine. In 2 weeks the dyspeptic disturbances occurred. Objectively: jaundice, liver is moderately increased and slightly painful. Reactions on antigen of hepatitis B and C are absent. What complication was evolved in this patient? (Liver functional test - 5, myelogram – 5.3, radio 1)
Evaluate instrumental and laboratory data
Dysproteinemia with Increase in globulin L1 n L2 indicate Acute Hepatitis.
Decrease total cholesterol indicates hepatocyte insufficiency.
Situational Task # 27
Male patient, 37 years old, for about one year had weakness, sweating and heaviness in the left hypochondrium especially after meals. On inspection splenomegaly and hepatomegaly were revealed. (CBC - 2.2, ECG А-10)
Evaluate instrumental and laboratory data
Situational Task # 28
A 35 year old female patient demonstrated not very frequent (about once a week) attacks of expiratory dyspnoea, which usually subsides by inhalation of short-acting β2-sympathomimetics. Objectively diffuse dry whistling rales can be heard on auscultation. In remission phase, the volume of forced expiration per 1 sec. exceeds more than 80% of normal value. (Sputum analysis - 3, spirogram – 1, X-ray 4, HRCT 1)
Evaluate instrumental and laboratory data
Curschmann’s crystals +
Charcot-Leyden crystals+
Conclusion= bronchial asthma
Situational Task # 29
Male patient, 42 year old, works in a mine during last 16 years. Complains of periodic cough, dyspnoea on moderate physical exertion, weight loss. On percussion band box sound all over the chest surface. Diffuse and dry rales over the all chest surface. (Sputum analysis - 12, x-ray - 28)
Evaluate instrumental and laboratory data
Situational Task # 30
A 22 year old male student fall sick acutely with elevated temperature up to 39°C, nonproductive cough, shooting-pain in right lateral chest region growing during inspiration and cough. In 3 days dyspnoea at rest developed. On chest percussion dull sound downwards from right scapula angle and weakened vocal trembling and impaired respiratory sounds were revealed. (Pleural fluid analysis - 13, roentgenogram – 8, USI 6)
Evaluate instrumental and laboratory data
A 46 year old male patient was admitted to the surgery department for urgent appendectomy. On the 4th day after surgery patient felt chills, cough, dyspnoea, temperature elevation up to 38.5ºC. Objectively weakened respiration and weakening of percussion sound were revealed over the upper part of right lung (Sputum analysis-5, CBC - 3.1, roentgenogram – 1)
Evaluate instrumental and laboratory data
Mucopurulent-----chronic bronchitis, TB
Leukocytes increase-----inflammatory
Erythrocyte increase----- acute lobar pneumonia, congestion in lesser circulation, lung infarction
Alveolar cell increase------pneumonia
Bacteria+---- cocci
Situational Task # 32
Female patient, 21 year old, complains of cough with secretion of about 100 ml of bloody sputum per day during last 8 years. Postural drainage has improved the patient’s condition and amount of sputum decreased. 3 days ago temperature increased up to 38ºC. Objective: on auscultation of posterior lower parts of both lungs moderate and large bubble rales can be heard, which decreases after coughing. (CBC - 3.1, urinalysis - 2, roentgenogram – 26, HRCT 2)
Evaluate instrumental and laboratory data
Situational Task # 33
A 59 year old man has hormone depending bronchial asthma. Complains of poor dry cough, subfebrile temperature, moderate weakness, slight weight loss last few months. Band box sound on percussion. Diffuse dry rales on auscultation. Reaction to Mantu’s test is negative. (CBC - 1.1, sputum analysis - 9, roentgenogram – 15, CT 6)
Evaluate instrumental and laboratory data
Decrease Hb Decrease CI Decrease Leu Increase lymphocytes Decrease Ht
Blood mucous Blood Leukocyte increase Erythrocyte increase Epithelial cell increase Atypical cell ++
Situational Task # 34
Male patient 34 years old complains on feeling of heaviness and pressure in the right hypochondrium, nausea and vomiting after eating of fried pork, dark urine and decreased intensity of stool color. From the anamnesis, it is known that 6 months ago he had viral hepatitis, and later didn't follow the diet recommendations. Objectively: subicteric sclera, abdomen is moderately distended. Liver edge is smooth with dense elastic consistency, stands 2 cm below the costal arch. (Liver functional test - 5, CBC – 27, USI 5)
Evaluate instrumental and laboratory data
Dysproteinemia with Increase in globulin L1 n L2 indicate Hepatitis.
Decrease total cholesterol indicates hepatocyte insufficiency.
Situational Task # 35
Male patient, 42 years old, complains on constant feeling of pressure in epigastria region, increasing after intake of food, recurrent nausea and vomiting with food eaten 1-2 days ago. He is sick during last 5 years. He has lost 5 kg of weight for last 3 months. Objectively: skin is dry, tongue is moist with white coating, on palpation of abdomen – phenomenon of "splash". Lower border of stomach is 4 cm below the umbilicus. (Blood biochemistry - 6.8, x-ray – 59)
Evaluate instrumental and laboratory data
Situational Task # 36
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”. (CBC - 1.1, x-ray – 64, CT 1)
Evaluate instrumental and laboratory data
Decrease RBC Decrease Hb Decrease CI Decrease Leu Increase lymphocytes Decrease Ht
Conclusion= iron deficiency anemia
#xray 64--> filling defect endophytic cancer of stomach
#ct 1--> present of irregular homgenous mass in the stomach
diagnosis: Gastric carcinoma.
Situational Task # 37
A 42 year old male patient complains of constant pain in epigastric region with irradiation to the spine, permanent nausea, periodically vomiting, weight loss. He was suffering from duodenal ulcer during last 16 years. Objectively: abdomen is tensed, painful on palpation in pyloroduodenal zone. Obratzsov symptom is positive. Subfebrile temperature. What can be the complication in this case? (CBC - 1.1, x-ray - 58)
Evaluate instrumental and laboratory data
Decrease RBC Decrease Hb Decrease CI Decrease Leu Increase lymphocytes Decrease Ht
Conclusion= iron deficiency anemia
#xray 58-->penetration of ulcer niche,have 3 layer (air fluid and barium)
diagnosis : Penetration of gastric ulcer.
Situational Task # 38
A 56 year old women complains on attack-like pain in right hypochondrium with irradiation to the right shoulder which appears after eating of fried food, periodically increased of subfebrile temperature. Stool is decolorizes and urine is dark. She is sick for the last 5 years. (CBC – 3.1, liver test - 11, USI – 4, MRI 1)
Evaluate instrumental and laboratory data
Dysproteinemia with increase globulin Beta n Gamma, increase moderately of AST n ALT indicates CHRONIC HEPATITIS.
Situation Task # 39
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. (CBC - 3.1, roentgenogram – 60)
Evaluate instrumental and laboratory data
Situational Task # 40
A 50 year old women complains of pain and stifness in small joints of hand, predominantely in proximal interphalangeal and metacarpophalangeal articulations, wrist, knees, restriction of joint movement, weakness. On inspection: swelling, defiguration, pain on palpation and passive movements in mentioned joints. (Blood biochemistry - 6.18, CBC - 1.11, roentgenogram – 41, USI 2)
Evaluate instrumental and laboratory data
Diagnosis = acute Rheumatic Fever
Fibrinogen 5-6 = 2nd degree
CRP +++ = 3rd degree
Situational Task # 41
A 35-aged women complains on headache, elevated BP, face edema in the morning. He is sick for the last 10 years. Status of the patient has worsened 2 weeks ago, when edema became total. Objectively: BP - 220/130 mm Hg, HR 110 bpm, heart sounds are arrhythmic, weakened, accent of S2 on aorta. (Urinalysis 19, renal function test - 13, ECG В-9, USI 1)
Evaluate instrumental and laboratory data
Heavy proteinuria >2,5 g/l
Cylinduria
Microhematuria
Relative density decreased
Chronic glomerulonephritis nephrotic syndrome
Situational Task # 42
A 32 year old male patient complains of BP elevation up to 240/130 mm Hg, severe headache. During last 5 years he periodically notes meat-like color of urine and edema of eyelids. The deterioration was happened after becoming too cold. (Urinalysis 20, renal function test - 13, ECG В-9)
Evaluate instrumental and laboratory data
Relative density decreased
Mild proteinuria
Situational Task # 43
An agricultural worker, 35 years old, after the prolonged spraying fruit-trees in the garden with chlorindan experienced rhinorrhea, dry cough, watering and 2 hours later headache, dizziness, nausea, vomiting, elevated To up to 39o appeared. On the next day the patient had pain in right hypochondrium, weakness and urine color like beer. Objectively: adynamia, skin and sclera are icteric. HR 104 bpm. BP-110/70 mm Hg. Abdomen is soft, painful in right hypochondrium, on palpation soft elastic, rounded edge of liver 3‑4 cm below the costal arch. (CBC – 61, blood biochemistry – 61)
Evaluate instrumental and laboratory data
>inflammatory process
Bilirubinemia
Increase direct and indirect
Increase AST & ALT
-->Parenchymal Hepatitis
diagnosis: Acute poisoning with chlorine organic hydrocarbons.
Situational Task # 44
A worker with chlororganic naphthalene (Halovax) after an accident he had weakness, headache, dizziness, impairment of movements coordination. On the next day he began to feel heaviness in epigastric region, nausea, increased body temperature up to 38.5ºC and dark urine. Objectively: skin is light brown color, sclera are icteric, tremor of hand, tachycardia. HR 96 bpm. BP 100/70 mm Hg. Abdomen is soft, painful in epigastric region, on palpation soft elastic, smooth edge of liver. Size of liver according to Kurlov: 12х12х10cm. Other symptom is positive on both sides. Diuresis is 300 ml. (CBC – 62, blood biochemistry – 62, urinalysis – 62)
Evaluate instrumental and laboratory data
Leukocytosis, regenerative shift to the left (increased Stab in presence of leukocytosis), Increased ESR indicate Inflammatory process
Bilirubinemia
Increase indirect & direct bilirubin
AST and ALT increase
Diagnosis = Parenchymal Hepatitis
Presence of microalbuminuria
Decrease in Relative density ( Norm 1015-1025)
Present erythrocyte = erythrocyturia
Colour dark
Transparency turbid
--> Acute glomerulonephritis Nephritic form
diagnosis :Acute poisoning with chlorine organic hydrocarbons.
Situational Task # 45
A laborer 48 years old, was working for the last 25 years with benzol products, complains of headache, dizziness, insomnia, weakness, pain in extremities, nausea, dull pain in right hypochondrium and nasal bleeding. He is sick for last 7 years. Objectively: skin and visible mucous are pale, tremor of arms, hyperhydrosis of hands. Positive symptom of pinching and tourniquet. Tachycardia, systolic murmur on apex. HR 96 bpm, BP 140/90 mm Hg. Abdomen is soft, painful in right hypochondrium, on palpation soft elastic, painful, smooth rounded edge of liver 3 cm below the costal arch. (CBC – 63, blood biochemistry – 63)
Evaluate instrumental and laboratory data
Anemia, thrombocytopenia, leukocytopenia indicate Pancytopenia
Increased bleeding time indicate platelet disorder. These condition may happen in (Aplastic anemia?)
Increase direct bilirubin Increase AST Increase ALT
Conclusion: hepatitis
diagnosis:Chronic benzol intoxication.
Situational Task # 46
A 52-aged worker with granosan (mercury chemical preparation) had headache, nausea, vomiting, metallic taste in mouth, pain in abdomen and watery stool. On the next day an elevation of temperature up to 38.5°С, pain in right hypochondrium and weakness were occurred. Objectively: bleeding from gums, skin is icteric, tremor of hands, tachycardia. HR 100 bpm, BP 90/60 mm Hg. Palpation – soft elastic, painful, smooth edge of liver, 3-4cm below costal arch. Size of liver according to Kurlov: 13x12x11cm. (CBC – 64, blood biochemistry – 64)
Evaluate instrumental and laboratory data
Leukocytosis, regenerative shift to left, increased ESR indicate inflammatory process. Monocytosis indicate development of immune process in chronic dss eg: malaria, tuberculosis, syphilis, chronic sepsis
Situational Task # 47
A 53 year old mechanic who works with accumulators complains on weakness, fatigue, numbness of upper extremities and pain in right hypochondrium. He is sick for the last 5 years. Objective: skin is pale earthy, violet border on the gums. Bradycardia, heart sounds are muffled with systolic murmur on the cardiac apex. HR 52 bpm. BP 110/70 mm Hg. Abdomen is soft, moderately painful in right hypochondrium, on palpation soft elastic, smooth edge of liver painless 1-2 cm below the rib arch. Size of liver according to Kurlov: 13x12x11cm. (CBC – 65, blood biochemistry – 65, urinalysis – 65)
Evaluate instrumental and laboratory data
Decreased RBC and Hb count, decreased CI indicate Hypochrmic anemia, reticulocytosis indicate erythropoiesis is activated (blood loss and hemolysis).
Erythrocyte with basophilic punctuation indicate ? anemia
Increase AST Increase ALT
Conclusion= chronic hepatitis
Colour pink
Rxn acidic
Tranparency turbid
Presence of Aminolevulinic acid and Coproporphyrinuria
Presence of WBC in urine.
Diagnosis = Lead intoxication
diagnosis :Chronic inorganic lead intoxication.
Situational Task # 48
A worker of brick factory, 52 years old, complains of cough with not large amount of sputum, decreased appetite, sweating, dyspnea at rest, subfebrile temperature up 37.50С. Heavy breathing with prolonged expiration over the lungs. HR 100 bpm. Hepatomegaly, ankle edema. (CBC – 66, x-ray - 6)
Evaluate instrumental and laboratory data
Leukocytosis, regenerative shift to the left (increased Stab in presence of leukocytosis), Increased ESR indicate Inflammatory process
Situational Task # 49
A 36 years old women complains of dyspnea with heavy expiration, cough with dense mucous sputum. Asthmatic attacks 1-2 times per week subsides after inhalation of salbutamol. For the last 16 years patient was working in cosmetic cabinet. Lips are cyanotic. HR 92 bpm. BP 120/80 mm Hg. Respiration is hard with prolonged expiration, single dry whistling rales. (Sputum analysis – 67, spirogram – 67, X-ray 5)
Evaluate instrumental and laboratory data
Presence of Curschmann's spirals ,Charcot-Leyden crystals, large amount of eosinophils, in colourless,mucous,viscous sputum indicate bronchial asthma.
diagnosis :Occupational bronchial asthma.
A 48 year old woman, works in a cement factory during the last 12 years. Anamnesis without any features. For the last 3 years, complains on constant cough with secretion of viscous sputum predominantly in the morning, Objectively: heavy breathing with prolonged expiration, dry rales over the lungs. Tiffno test - 48% of normal. (Sputum analysis – 68, spirogram – 68, X-ray 17)
Evaluate instrumental and laboratory data
Presence of elastic fibers, increase amount of leucocytes and epithelial cells indicate bronchitis.
diagnosis :Occupational dust bronchitis.
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Typical task 1
The patient 59 years old came to clinic within 3 hours after beginning of anginous status. BP - 130/80 mm g, heart rate 92 per minute. On electrocardiogram – elevation of ST segment in I, avL and V2-4 on 3-6 mm.
The clinical diagnosis: IHD: myocardial infarction of anterior apex, heart failure 0 degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 1.
1. Oxygen. Analgetics (Morphine of 1,0 ml i.v. with atropine. Probably neuroleptanalgesia - Fentanyl with Droperidol, or nitrous oxide)
Antiaggregants (Aspirin of 0,125-0,325 mg/d), thrombolytic agents (Streptokinase or Alteplase (Actilise) i.v. within an hour), anticoagulants (Heparin or Fraxiparine).
Beta-blockers (metoprolol) under the control of the Cardiac rate and BP
2. Rp.: Sol.Morphini hydrochloridi 1% - 1ml
D.t.d. N 6 in amp.
S. 1 ml subcutaneously
#
Rp: Tab. Simvastatini 0,02 № 50
D.S. 1 tablet 1 time per day in the evening
#
Rp: Tab. Captoprili 0,05 № 20,
D.S 1/2 tablet 3 times per day
#
Rp.: Tab. Metoprololi 0,05 N 20.
D.S. 1/2 tablet 2 times per day.
#
Rp: Tab. Acidi acetylsalicylici 0,1 № 10
D.S. 1 tablet 1 time per day in the evening
Typical task 2
The patient 52 years old complains of dyspnea and palpitation at insignificant physical activity. Heart rate - 92 per minute, rhythmic, BP 120/80 mm Hg. Respiratory rate 22 per minute, single moist rales in the lower part of the lungs. On echocardiogram: size of the left ventricular cavity is enlarged; the ejection fraction is lowered up to 37 %. Peripheral edemas are not present.
The clinical diagnosis: IHD: postinfaction cardiosclerosis, aneurysm of the anterior wall of left ventricle, heart failure II A degree, III functional class.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 2.
1. To limit exercise stresses, a diet with table salt and fluid restriction. Control of a body weight and a daily diuresis.
Heart failure treatment: Furosemid in a combination to potassium preparations, potassium-sparing diuretics (Spironolactone). Angiotensin converting enzyme (ACE) inhibitors (enalapril, perindopril), since small doses. Or beta-blockers, since small doses with gradual augmentation to target (metoprolol from a dose of 6,25-12,5 mg/day).
For the purpose of thrombogenesis preventive maintenance - acetylsalicylic acid 100 mg /day over a long period of time.
2. Rp: Tab. Furosemidi 0,04 № 10
D.S. 1 tablet on an empty stomach in the morning 2 times per week
#
Rp: Tab. Perindopril 0,004 № 30
D.S. 1 tablet in the morning.
#
Rp.: Tab. Metoprololi 0,025 N 20.
D.S. 1/2 tablet 2 times per day.
#
Rp: Tab. Atorvastatini 0,02 № 50
D.S. 1 tablet 1 time per day in the evening
#
Rp: Tab. Acidi acetylsalicylici 0,1 № 10
D.S. 1 tablet 1 time per day in the evening
Typical task 3
The man 37 years old complains of fever 37-37,50С, constant pains in the heart region, dyspnea at moderate physical activity. In blood eosinophilia, elevated ESR. The clinical diagnosis: Acute exudative pericarditis. The diagnosis is confirmed by X-ray examination and according to echocardiogram.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№3
1. A bed rest, diet with table salt and fluid restriction.
Nonsteroidal antiinflammatory drugs – COX-2-inhibitors (Nimesulid 100 mg 2 times/day). In the absence of improvement to on 3-5 days of therapy it is possible to prescribe glucocorticoids - Prednisolon 15-30 mg per day in first half of a day. After reception of clinical effect a dose reduce gradually before cessation of therapy. Diuretics under indications.
At appearance of signs of tamponade - pericardiocentesis.
2. Rp.: Meloxicami 0,0075
D.t.d. N 20 in tab.
S. 1 tablet 1 time per day after meals
#
Rp: Tab. Prednisoloni 0,005 № 20
D.S. 1 tablet 3 times per day.
#
Rp: Tab. Hypothiazidi 0,1 № 20
D.S. 1/2 tablet 1 time per day.
Typical task 4
The woman 58 years old, cashier, complains of periodical arising of headache at the end of working day and pressing pain in frontal region.
Objectively: skin is pale, increased appetite (height of 160 cm, weight of 78 kg). The BP - 160/100 - 170/105 mm Hg, heart rate 60-66 per minute and rhythmic.
The clinical diagnosis: Essential hypertension II stage, moderate, heart failure 0 degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№4
1. Correction of major risk factors - diet, moderate physical activity, restriction of psycho-emotional stress.
Angiotensin converting enzyme (ACE) inhibitors (enalapril, perindopril, lisinopril).
Thiazide or thiazide-like diuretics (hydrochlorthiazide, indapamide).
Application of the combined preparations (noliprel) is possible.
2. Rp: Tab. Lisinoprili 0,01 № 30
D.S. 1 tablet in the morning.
#
Rp: Tab. Hydrochlorthiazidi 0,1 № 20
D.S. 1/2 tablet 1 time per day.
Typical task 5
A 48-year-old man, a surgeon, suffers from angina pectoris for 2 years, it was not treated, and he is a chain smoker, frequently on night duty at emergency department of hospital. BP 135/85 mm Hg, heart rate 80 per minute. The General cholesterol level 5,8 mmol/l.
The clinical diagnosis: IHD: angina pectoris II functional class, heart failure 0 degree. The diagnosis is confirmed by bicycle ergometry and Holter’s monitoring of electrocardiogram.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№5
1. Correction of major risk factors- weight reduction, moderate physical activity, diet, moderate physical activity.
Nitrites of short action at an anginous attack (Nitroglycerin).
Appointment of cardioselective beta-blockers (metoprolol, bisoprolol, betaxolol).
Aspirin (aspecard). Statins.
2. Rp: Tab. Simvastatini 0,002 № 40
D.S. 1 tablet 1 time per day in the evening
#
Rp: Tab. Nitroglycerini 0,0005 № 50
D.S. 1 sublingual tablet at a retrosternal pain.
#
Rp.: Tab. Metoprololi 0,05 N 20.
D.S. 1/2 tablet 2 times per day.
#
Rp: Tab. Acidi acetylsalicylici 0,1 № 10
D.S. 1 tablet 1 time per day in the evening
Typical task 6
The male patient 22 years old complains of thirst, dry mouth, polyuria, weakness, prominent loss of weight. He experienced symptoms of acute respiratory viral infection about a month ago. The patient body weight – 58 kg, body height – 170cm. On examination skin is dry. Respiration is vesicular. Respiratory rate is 20 per minute. Heart rate is 94 per minute. BP 140/ 80 mm Hg. The tongue is dry. On palpation the abdomen is soft and painless. Daily diuresis is 3,l l. Glucose blood level is 19 mmol/l, urinalysis: glucose, acetone + are detected. The clinical diagnosis: Diabetes mellitus type 1.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№6
1. Diet #9, adequate physical regimen, Insulin therapy ( intensive or traditional scheme).
2. Rp: Insulini “Actrapid Penfill” 3,0 ml (100 IU/ml)
D.t.d #2
S. Draw SC 4 IU in 20 minutes before breakfast, 6 IU in 20 minutes before lunch, 4 IU before dinner
Rp: Insulini “Protaphan Penfill” 3,0ml (100IU/ml)
D.t.d #2
S. Draw SC 6 IU at 08:00, 8 IU at 20:00
Typical task 7
The female patient 54 years old with complaints of itching of genitals, has come at reception to the gynecologist. On interrogation other complaints of dry mouth, polygraph, general weakness were taken. The patient body weight – 102 kg, body height – 160cm. BMI 38,5. On examination the skin is dry, with traces from scratches. Respiration is vesicular. Respiratory rate is 20 per minute. Heart rate is 86 per minute. BP 170/ 95 mm Hg. The tongue is dry. On palpation the abdomen is soft and painless. The fasting level of glycemia – 7,9 mmol/l. Content of glucose in urine – 1%, Daily diuresis is 2,5 l.
Postprandial glucose blood level is 14mmol/l, urinalysis: glucose is detected.
HbA1c- 9,4%.Total cholesterol 9,2 mmol/l, ALT 0,3 mmol/hr×l, AST 0,28 mmol/hr×l
The clinical diagnosis: Diabetes mellitus type 2. Obesity 2nd degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№7.
1. Diet #9, adequate physical regimen, glucose lowering drugs (Metformin, Sulfonylureas – Gliklazide or Glimeperide), Atorvastatin 20 mg in the evening.
2. Rp: Tab. Metformini – 0,5
D.t.d # 60
S. Intake 1 tab PO BID during having meal at 08:00 and 20:00
Rp: Tab. Gliklazidi 0,03
D.t.d #60
S. Intake 2 tab during having a breakfast PO OD
Rp: Tab. Atorvastatini 0,02
D.t.d #30
S. Intake 1 tab PO OD in the evening (21:00)
Typical task 8
The patient B, 17 years old, complains of dyspnea at insignificant physical activity, palpitation, fast fatigue. Suffers since the childhood. Diffused cyanosis, thickening of tips of fingers of the hands, clubbing of fingers. Auscultation along left edge of sternum, rough systolic murmurs, maximum above the III intercostal space and accent of II tone above pulmonary artery is detected. Heart rate 92 per minute, BP 120/70 mm Hg. Doppler echocardiography: ventricular septal defect.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№8
1. Appointment of small doses of ACE-inhibitors, dihydropyridines calcium channel blockers (amlodipin). To decide a question on possibility of operative treatment.
2. Rp.: Tab. Amlodipini 0,005 N 28
D.S. 1/2 tablet 1-2 times per day.
#
Rp: Tab. Lisinoprili 0,01 № 30
D.S. 1/2 tablet in the morning.
Typical task 9
The patient B, 30 years old, complains of dyspnea at moderate physical activity, palpitation, and cough with scanty sputum with streaks of blood. Acrocyanosis. Vesicular breathing, above lower parts of the lungs solitary moist small bubble rales are heard. Tones of heart are arrhythmic, heart rate 92 per minute, accentuation of I tone on the heart apex, triple rhythm on the same place, accompanied with diastolic murmurs, accent of II tone on pulmonary artery. Pulse 82 per minute, arrhythmic, varying filling pressure, BP 140/90 mm Hg. Doppler echocardiography: signs of mitral stenosis. ECG: atrial fibrillation.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№9
1. Appointment of diuretics (furosemide in a combination to potassium preparations, thiozides, potassium-sparing diuretics (Spironolactone), small doses of beta-blockers and ACE-inhibitors. To decide a question on possibility of operative treatment.
2. Rp.: Tab. Metoprololi 0,05 N 20.
D.S. 1/2 tablet 2 times per day.
#
Rp: Tab. Enalaprili 0,01 № 30
D.S. 1/2 tablet in the morning 2 times a day.
#
Rp: Dr. Spironolactoni 0,025 № 10
D.S. 1 dragee in the morning
#
Typical task 10
The patient 40 years old complains of dyspnea at mild physical exertion, heaviness in the right hypochondrium. Moist rales up to middle of the lungs, BP 130/80 mm Hg, liver is smooth and slightly painful on palpation.
The clinical diagnosis: dilated cardiomyopathy, heart failure II B.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№10.
1. Appointment of ACE-inhibitors, cardiac glycosides, diuretics, potassium preparations. At condition improvement - beta-blockers.
2. Rp.: Tab. Spironolactoni 0,025 N 100.
D.S. 2 tablet 1 time per day in the morning.
#
Rp: Tab. Furosemidi 0,04 № 10
D.S. 1 tablet on an empty stomach in the morning 2 times per week
#
Rp.: Tab. Metoprololi 0,05 N 20.
D.S. 1/2 tablet 2 times per day.
#
Rp: Tab. Digoxini 0,00025 № 50
D.S. 1 tablet 1-2 times per day
Typical task 11
Patient 26 years old complains of dyspnea at insignificant physical activity, headache, dizziness, episodic pain in the heart area. Subfebrile temperature was noticed for 2 weeks, sweating. Objectively: pale, pulsation of carotid artery. Vesicular breathing, weakened above lower parts of the lungs. Tones of heart are muffled, rhythmic, II tone above the aorta and in Botkin’s point is sharply weakened, soft diastolic murmurs are heard. Heart rate 100 per minute, BP of 160/50 mm Hg Doppler echocardiography: vegetation on aortic valve.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 11.
1. Infectious endocarditis. Wide spectrum antibiotics (after blood culture investigation and according to antibiotic sensitivity) 4-6 weeks - penicillin + aminoglycoside, ceftriaxone + gentamicin, vancomycin, imipenem. Fungal endocarditis requires specific anti-fungal treatment, such as amphotericin B. ACE-inhibitor, b-blocker and small doses of diuretics are indicated. Surgery may be needed to replace damaged heart valves.
2. Rp.: Amikacin 0.5
D.t.d. N 20 in amp.
S. i/m 2-3 times a day in a dose of 7,5 мg/кg dissolved in the water for injection.
Rp.: Tab. Amoxicillin/clavulanic acid 0,5/0.125 N 14
S. 2 tablet 2 times per day.
Rp.: Tab. Bisoprololi 0,005 N 20
D.S. 1 tab. 1 time a day before meal.
Rp.: Tab. Enalaprili 0,01 N 20
D.S. 1/2 tab. 2 times a day before meal.
Rp.: Tab. Furosemide 0,04 N 10
D.S. 1 tab. 1 time in 3 days in the morning before meal.
Typical task 12
Patient 59 years old complains of persistent dry cough, dyspnea at moderate physical activity, fatigue, periodic edema in the lower extremities. History of cough for 20 years. Smokes from 14 years of age, now up to 2 packs of cigarettes per day. Slight edema of feet and shins. The thorax is barrel-shaped. Lung percussion reveals band box sound. Harsh breathing, dissipated multiple dry rales. Weakened apex beat, borders of relative heart dullness are expanded to the right. Tones of heart are muffled, rhythmic. Heart rate 98 per minute, BP of 120/80 mm Hg. The liver border extends on 6 cm from rib arch. The diagnosis: cor pulmonale, heart failure II A.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 12.
1. Cancellation of smoking. Prescribing of ACE-inhibitor, diuretics, potassium drugs, bronchodilators.
2. Rp.: Aerosoli Formoteroli (100 doses)
D.S. 12 mkg (1 dose) 2 times a day.
Rp.: Sol. Furosemidi 1% - 2 ml
D.t.d. N 6 in amp.
S. 2-4 ml i/m
Rp.: Tab. Perindoprili 0,005 N 20
D.S. 1 tab. 1 time a day before meal.
Typical task 13
Patient 19 years old disturbed by attacks of heart palpitation arising without a visible reason for 1-2 times a month since childhood. It proceeds from 5 till 15-20 minutes and disappears usually by itself. Electrocardiogram during the moment of an attack: atrioventricular reciprocal tachycardia. Electrocardiogram during attack free times - reveals signs of Wolff Parkinson White syndrome (WPW).
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 13.
1. WPW syndrome, paroxysmal a-v nodal tachycardia.
For rapid relief of paroxysm Na-adenophosphate or amiodaron are using. If no response – electrical cardioversion. Radio-frequency catheter ablation of additional Kent bundle is a choice therapy.
2. Rp.: Sol. Amiodaroni 5% - 3 ml
D.t.d. N 6 in amp.
S. i/v infusion of 3-6 ml of amiodaroni with sol. Glucosae 5% - 200 ml.
Typical task 14
Patient 65 years old complains of attacks of heart palpitation during 2 years, accompanied with dizziness, dyspnea at insignificant physical activity, slight edema of feet and shins. Heart borders dilate to all sides, heart rate 96 per minute, pulse 86 per minute, arrhythmic. The BP 130/80 mm Hg. The lower edge of the liver extends below costal arch on 5 cm. Electrocardiogram during an attack registers tachysystolic type of atrial fibrillation.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 14.
1. For cardioversion – amiodarone. To prevent attacks of atrial fibrillation beta-blockers or amiodarone. Diuretics, ACE-inhibitors, potassium drugs. Anticoagulants (warfarin).
2. Rp.: Sol. Amiodaroni 5% - 3 ml
D.t.d. N 6 in amp.
S. i/v infusion of 3-6 ml of amiodaroni with sol. Glucosae 5% - 200 ml.
Rp.: Tab. Amiodaroni 0,2 N 50
D.S. 1 tab 3 time a day (1st week), 1 tab 2 time a day (2nd week), 1 tab 1 time a day for a long time
Rp.: Tab. Warfarini 0,005 N 30
D.S. 0,5-1 tab. 1 time a day under the control of INR.
Rp.: Tab. Lisinoprili 0,01 N 20
D.S. 1 tab. 1 time a day before meal.
Typical task 15
Patient K, 70 years old, is hospitalized in connection with the appeared frequent episodes of short-term loss of consciousness started 2 weeks ago. Objectively: vesicular breathing, weakened above the lower parts of the lungs. Respiratory rate 24 per minute. Left border of relative cardiac dullness is defined in V intercostal space on 2 cm externally from left mediaclavicular line. Tones of heart are loud, rhythmic. Heart rate 26 per minute, the BP 140/80 mm Hg. Electrocardiogram: atrioventricular blockade of III degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 15.
1. Implantation of pacemaker. Symptomatic treatment with beta-agonists, anticholinergic drugs, aminophylline - to increase HR.
2. Rp.: Sol. Atropini sulfati 1% - 1 ml
D.t.d. N 1 in amp.
S. 1 ml i/v
Rp.: Tab. Theophyllini 0,3 N 20
D.S. 1 tab. 2 times a day.
Typical task 16
Patient C, 21 year old (weight 55 kg), is hospitalized with the diagnosis: systemic lupus erythomatosis, acute course, active phase, activeness of III degree "butterfly rash" on the skin of the face, polyarthritis, exudative pleuritis, pericarditis, lupus-nephritis, heart failure I, respiratory insufficiency II.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 16.
1. diet №7. Pulse-therapy with glucocorticoids: metylprednisolone 1000 mg i/v 1 time a day 3 days. Later – prednisolone 1 mg/kg a day in the first half of a day, low doses of cytostatics (azathioprin 50 mg). Plasmapheresis & hemosorption. Disaggregant, anticoagulant (dipiridamol, heparin). In arising of hydrothorax the pleural puncture with an exudate evacuation and intrapleural steroids are indicated.
2. Rp.: Sol.Prednisoloni 3% - 2 ml
D.t.d. N 100 in. amp.
S. Dissolve in the 0,9% NaCl - 200 ml, intravenous infusion, 1 mg/kg.
Rp.: Tab. Azathloprini 0,05 N 50
D.S. 1 mg/kg a day.
Rp.: Sol. Heparini 5 ml (5000 U /ml)
D.t.d.N 5 in. flac.
S. 1 ml (5000 U) 3 times a day subskin.
Typical task 17
Patient K, 29 years old suffers from nodular polyarteritis, active phase, III degree of activeness, initial stage, with polyneuritis, trophic ulcers in the skin of lower extremities, coronariitis with angina syndrome, polyarthritis, joint insufficiency II degree, nephritis with arterial hypertension without uremic syndrome.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 17.
1. diet №7. Prednisolone 60 mg a day, gradual reduction of the dose up to supportive 5-15 mg a day. In case of resistance to the therapy - pulse-therapy with glucocorticoids: metylprednisolone 1000 mg i/v 1 time a day 3 days with cyclophosphamide 1000 mg in the first day. Plasmapheresis, immunoadsorption. Symptomatic therapy (NSAIDs, nitrates, ACE-inhibitors, disaggregants).
2. Rp.: Tab. Prednisoloni 0,005 N 20.
D.S. 6 pills - 8 a.m., 4 pills -12 p.m., 2 pills-14 p.m. after meal.
Rp.: Methylprednisoloni 1,0
D.t.d. N 1 in vial.
S. i/v 1 time a day a day 3 days dissolved in 5 ml of isotonic solution.
Rp.: Cyclophosphamidi 0,2
D.t.d. N 5 in fluc.
S. i/v infusion with 400 ml of isotonic solution 2 time per week
Typical task 18
The patient C, 39 years old, suffers from rheumatoid arthritis, polyarthritis with impairment of knee, hands and feet joints, seropositive variant, active phase, activeness II degree, X-ray II degree, joint insufficiency - I.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 18.
1. NSAIDs. In case of low efficacy – glucocorticoids (prednisolone 1 mg/kg a day). Basic therapy with cytostatics (metatrexate 7,5 mg 1 time a week).
2. Rp.: Tab. Ibuprofenі 0.2
D.t.d. N 20 in tab.
S. 1 pill 3 times a day during a meal.
Rp.: Tab. Methotrexati 0,005
D.t.d. N 50 in tab.
S. 1,5 pills 1 time a week 2 hours after or 1 hour before a meal.
Typical task 19
The female patient 30 years old complaints of weakness, sweating, tremor in a body, loss of weight, palpitation, increase of the sizes of neck, lacrimation, photophobia, dysmenorrhea. On examination: symmetric exophtalmos, a thyroid gland is diffusely enlarged, elastic, mobile, painless on palpation. Skin is moist. Respiration is vesicular. Respiratory rate 18 per minute. Cardiac sounds are sonorous, arrhythmic. Heart rate –112-128 per minute, pulse rate 100-106 per minute. BP 160/ 80 mm Hg. Gastrointestinal system: nothing abnormal was detected. Daily diuresis 2,0 l.
The clinical diagnosis: Diffuse toxic goiter, severe degree of thyrotoxicosis. Atrial fibrillation, tachysystolic form
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 19.
1. Thyrostatic treatment ( Merkasolil 50-60 mg/day, or Propilthyoracil 400-600mg/day. ß-blockers (Propranolol, or Metoprolol). Sedative drugs.
2. Rp: Tab. Mercasolili 0,005
D.t.d #50
S. Intake 2 tab TID PO after meal
Rp: Tab. Propranololi 0,01
D.t.d #50
S. Intake 2 tab BID PO in 10 minutes before meal in the morning and in the evening
Rp: Tab. Valerianae
D.t.d #50
S. Intake 2 tab TID PO
Typical task 20
48 years old man complains of cough with secretion of purulent sputum up to 50-150 ml a day, mainly in the morning, sometimes with impurity of blood, general weakness, sweating, fever, dyspnea at insignificant physical activity, rise in body temperature up to 39°С, followed by chill on the evening.
Objectively: skin of ground color shade, clubbing of fingers. Auscultation of lower lobe of the left lung reveals small bubble moist and dry rales. Bronchography: cylindrical bronchoecthasis in the lower lobes of both lungs.
Diagnosis: bronchoecthatic disease, moderate degree of severity, phase of exacerbation, bilateral cylindrical bronchoecthasis, pulmonary insufficiency II degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 20.
1. Excessive water intake. Antibacterial therapy (according to antibiotic sensitivity): ampyox or ceftriaxone 1 g endobronchially with bronchoscope in the morning and 1 g i/m in the evening. Tobramycin in the inhalations 2 times a day. Instillation of antiseptics: furacilin 10 ml of 1:1000 solution. Mucolytics: lasolvan, ambroxol, acetylcystein. Desintoxication.
2. Rp: Ceftriaxone 1,0
D.t.d. № 20 in flac.
S. dissolve in the 4 ml of water for injection i/m 2 times a day
Rp.: Tab. Аcetylcysteini 0,2 N 10
D.S. 1 pill 3 time a day after a meal.
Typical task 21
34 years old patient suffers from bronchial asthma for 19 years. Frequency of night episodes - 2 times a week, daytime episodes - daily. Dyspnea at insignificant physical activity. Ventilation function test: variability index - 38 %, FEV1 - 70 %. Diagnosis: bronchial asthma, III degree. Pulmonary insufficiency I degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 21.
1. Control of triggering factors.
Drug therapy. Bronchodilators: β2-agonists -- short-acting β2-agonists (eg, albuterol) inhaled 2 puffs q 4 h as needed are the drug of choice for relieving acute bronchoconstriction. Long-acting β2-agonists (eg, salmeterol) are active for up to 12 h and are used for moderate and severe asthma. Anticholinergics -- Ipratropium.
Corticosteroids -- medium-dose inhaled corticosteroid or low-dose inhaled corticosteroid plus long-acting β2-agonist (fluticasone 500 to 1000 μg/day and beclomethasone 400 to 2000 μg/day). Leukotriene modifiers (zafirlukast 20 mg 2 twice/day). Mast cell stabilizers (cromolyn sodium - nebulization solution: Initial: 20 mg 4 times/day; usual dose: 20 mg 3-4 times/day. Methylxanthines (theophylline)
Monitoring response to treatment
Patient education
Treatment of acute exacerbations
2. Rp: Aerosoli Salmeteroli 60 doses (0,000025 in 1 dose) №1
D.S. For inhalation 1-2 doses twice/day approximately every 12 hours (morning and evening)
Rp: Aerosoli Fluticasoni 60 doses (0,00025 in 1 dose) №1
D.S. Oral Inhalation, 1-2 doses twice/day.
Rp: Сromolyn sodium 0,02
D.t.d № 30 in caps.
S. For inhalation 20 mg 4 times/day.
Typical task 22
52 years old man smokes for 33 years, complaints on constant cough, dyspnea increasing at moderate physical activity. Dry whistling rales over the all lungs surface. Spirography: FEV1 67 %, Tiffno’s index 62 %, variable index 8 %. The diagnosis is chronic obstructive pulmonary disease II stage, pulmonary insufficiency II degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 22.
1. Regular treatment with one or more bronchodilators
Drug therapy: Inhaled bronchodilators are the mainstay of COPD management; drugs include β-agonists -- albuterol aerosol, 2 puffs (90 to 100 μg/puff) inhaled from a metered-dose inhaler 4 to 6 times/day prn, salmeterol powder, 1 puff (50 μg) inhaled bid, and formoterol powder, one puff (12 μg) inhaled bid. Anticholinergics -- Ipratropium dose is 2 to 4 puffs (18 μg/puff) from a metered-dose inhaler q 4 to 6 h; Tiotropium - 18 μg once/day/
Corticosteroids are indicated for patients who have repeated exacerbations or symptoms despite optimal bronchodilator therapy (fluticasone 500 to 1000 μg/day and beclomethasone 400 to 2000 μg/day.
Theophylline can be used for patients who have not adequately responded to inhaled drugs and who have shown symptomatic benefit from a trial of the drug.
Oxygen therapy
Smoking cessation
Annual influenza vaccinations
Rehabilitation
2. Rp: Tiotropium bromide 0,000018.
D.t.d. №30 in caps.
S. Oral inhalation only using a special oral inhalation device (HandiHaler), 18 mcg (contents of one capsule) once daily.
Rp: Aerosoli Salmeteroli 60 doses (0,000025 in 1 dose) №1
D.S. For inhalation 1-2 doses twice/day approximately every 12 hours (morning and evening)
Rp: Aerosoli Fluticasoni 60 doses (0,00025 in 1 dose) №1
D.S. Oral Inhalation, 1-2 doses twice/day.
Typical task 23
72 years old man 3 weeks after adenomectomy felt weakness, sudden dyspnea, hemoptysis, right side pleuritic chest pain, cough. Inspection: pale, breathing rate 30 per minute, auscultation - rales on the lower lobe of the right lung, tones of heart are muffled, rhythmic, heart rate 94 per minute, AP 115/70 mm hg. ECG: sinus tachycardia, syndrome SI-QIII, incomplete right bundle branch block, body temperature 36,7.
The clinical diagnosis: pulmonary embolism.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 23.
1. All patients with strongly suspected or confirmed PE should be hospitalized and, ideally, should also be continually monitored for life-threatening cardiovascular complications in the first 24 to 48 h.
Initial treatment of PE is O2 for hypoxemia and IV 0.9% saline and vasopressors for hypotension and anticoagulation. Heparin, either unfractionated or low mol wt, is the mainstay of treatment of acute DVT and PE and should be given immediately on diagnosis or sooner if clinical suspicion is high and if the patient has cardiorespiratory compromise. Unfractionated heparin should be given as a bolus and infusion by protocol (Weight-based heparin dosing.) to achieve an activated PTT 1.5 to 2.5 times that of normal control. Enoxaparin 1 mg/kg sc q 12 h or 1.5 mg/kg sc once/day. Warfarin is the oral drug of choice for long-term anticoagulation. 5 to 10 mg po once/day should be started when the PTT has been consistently ≥ 1.5 to 2.0 times control values, then 2–5 mg po once/day, therapeutic goal with warfarin is usually an INR of 2 to 3.
CPR in cardiorespiratory arrest.
Inferior vena cava filter placement when anticoagulation contraindicated or ineffective
Clot elimination (eg, thrombolytic therapy, embolectomy) for massive emboli. Clot elimination by means of embolectomy or dissolution by IV thrombolytic therapy should be considered for hypotensive patients. It may also be indicated for patients with clinical, ECG, or echocardiographic evidence of right ventricular overload or failure.
2. Rp.: Tab. Warfarini 0,005 N 30
D.S. 0,5-1 tab. 1 time a day under the control of INR.
Rp.: Sol. Heparini 5 ml (5000 U /ml)
D.t.d.N 5 in. flac.
S. 1 ml (5000 U) 3 times a day subskin.
Typical task 24
62 years oldman complains of increased body temperature up to 39,40С, fever, sweating, cough with rusty sputum, dyspnea, pain during deep breathing in the right half of thorax. He became ill acutely last night.
Objectively: skin is pale. The right half of thorax lags behind during the breathing act. Vocal fremitus is strengthened above the right upper part, percussion sound is dulled, rales and bronchophony. Breathing rate - 27 per minute. Heart sounds are clear, rhythmic. Heart rate - 98 per minute. BP 110/70 mm hg. СВС: leukocytes - 11,5х109/l, ESR - 28 mm/h. Blood fibrinogen - 6 g/l, SRP +. culture of sputum - Streptococcus pneumoniae positive. Diagnosis is community-acquired pneumonia.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 24.
- Macrolide (azithromycin 500 mg po once, then 250 mg once/day; clarithromycin 250to 500 mg po bid; or extended-release clarithromycin 1 g once/day), amoxicillin 1 g q 8 h; amoxicillin/clavulanate 875/125 mg q 12 h) or antipneumococcal fluoroquinolone (alone) po – levofloxacin, gatyfloxacin. Supportive care includes fluids, antipyretics, analgesics, and for patients with hypoxemia O2.
- Rp: Tab. Azithromycini 0,5 №3
D.S. 1 tab once daily for 3 days
Rp.: Tab. Amoxicillin/clavulanic acid 0,875/0,125 N 14
D.S. 1 tablet 2 times per day.
Rp: Tab. Levofloxacini 0,5 №10
D.S. 1 tab once every 24 hours for 7–14 days
Typical task 25
A young man complaints of weakness, increased body temperature, cough with small quantity of mucous-purulent sputum. He was ill for last 3 days, after he was caught a chill.
Objectively: body temperature 37,50С, insignificant hyperemia of uvula, auscultation of the lung reveals moderate caliber moist rales in the upper lobes of the lungs, breathing rate 20 per minute. Heart sounds are clear and rhythmic, pulse 80 per minute, rhythmic, BP 120/80 mm hg. CBC: slight leukocytosis and increased ESR.
Diagnosis: acute bronchitis, pulmonary insufficiency O degree
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 25.
1. Symptomatic relief (acetaminophen, hydration, possibly antitussives, secretolytic agents – ambroxol, acetylcysteine)
Inhaled β-agonist or anticholinergic for wheezing
Sometimes oral antibiotics for patients with COPD (amoxicillin 500 mg po tid for 7 days, doxycycline 100 mg po bid for 7 days, azithromycin 500 mg po once/day for 4 days
2. Rp: Tab. Ambroxoli hydrochloridi 0,03 № 20
D.S. 1 tab 2-3 times/day
Rp: Tab. Azithromycini 0,5 №3
D.S. 1 tab once daily for 3 days
Rp: Tab. Amoxicillini 0,5 № 20
D.S. 1-2 tab every 8 hours.
Typical task 26
22 years old patient was hospitalized with complaints of weakness, cough with mucous-purulent sputum, sometimes with blood streak, increased body temperature up to 38-390С, pain in the right half of the thorax, amplifying at cough.
Percussion of lungs reveals pulmonary sound, on auscultation - vesicular breathing is weakened below scapular on the right side, in the same place – silent and loud rales, crepitation.
The condition became worse in 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 lung vocal fremitus can’t be heard. Percussion: dull sound; auscultation of the dull sound zone reveals sharply weakened respiration, breathing is absent in the lower part. The analysis of blood: leukocytes - 17,5 х109/l, stab cells - 11 %, ESR-43 mm/hr.
Diagnosis: community-acquired pneumonia of lower lobe of right lung, severe course, exudative pleurisy of right side, pulmonary insufficiency II degree.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 26.
1. In the presence of adverse prognostic factors (pH < 7.20, glucose < 60 mg/dL, positive Gram stain or culture, loculations), the effusion should be completely drained via 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 500 mg po q 12 h; amoxicillin 1 g q 8 h; amoxicillin/clavulanate 875/125 mg q 12 h) plus A macrolide po or
Antipneumococcal fluoroquinolone (alone) po; Azithromycin 500 mg IV q 24 h plus β-lactam IV (cefotaxime 1 to 2 g q 8 to 12 h; ceftriaxone 1 g q 24 h). Supportive care includes fluids, antipyretics, analgesics, and for patients with hypoxemia O2.
2. Rp: Tab. Azithromycini 0,5 №3
D.S. 1 tab once daily for 3 days
Rp.: Tab. Amoxicillin/clavulanic acid 0,875/0,125 N 14
D.S. 1 tablet 2 times per day.
Rp: Ceftriaxone 1,0
D.t.d. № 20 in flac.
S. dissolve in the 4 ml of water for injection i/m 2 times a day
Typical task 27
43 years old patient admitted to hospital with complaints of face and legs edema, headache, dysuria, presence of dark red urine. He suffered from glomerulonephritis for 12 years. Vesicular breathing is weakened; heart sounds are arrhythmic, muffled, heart rate 98 per minute; BP 160/100 mm Hg. Anemia. Daily diuresis 560 ml, daily proteinuria 4,5 g/L, general urine analysis: relative density - 1011, protein 1,7 g/L, Er. - 15-17, leukocytes 3-4, hyalinic casts - 6-8. Creatinine 0,26 mmol/l, urea 15 mmol/l, glomerular filtration 45 ml/minute, potassium in blood - 5,1 mmol/l.
Diagnosis: Chronic glomerulonephritis, nephrotic syndrome. Symptomatic arterial hypertension. Chronic renal insufficiency II stage.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 27.
1. Treatment of causative disorder.
Immunosuppressive therapy: Corticosteroids (eg, prednisone 1 mg/kg po once/day or 2 mg/kg every other day) are recommended, Sometimes cyclophosphamide (2 to 3 mg/kg once/day) or cyclosporine (1.5 to 2 mg/kg po bid).
Angiotensin inhibition (ACE inhibitor or angiotensin II receptor blocker is indicated for patients with even mild hypertension (eg, BP > 130/80 mm Hg) or proteinuria).
Na restriction (< 2 g Na, or about 100 mmol/day) is recommended for patients with symptomatic edema.
Loop diuretics are usually required to control edema but may worsen preexisting renal insufficiency and hypovolemia, hyperviscosity, and hypercoagulability and thus should be used only if Na restriction is ineffective.
Statins (hyperlipidemia and risk factors for atherosclerosis should be treated aggressively).
Dipyridamole (225-450 mg po once/day) with aspirin (250-500 mg po once/day) for 1 yr may stabilize renal function at 3 to 5 yr.
Possible restriction of dietary protein, phosphate, and K
Vitamin D supplements
Treatment of anemia and heart failure
Dialysis for severely decreased GFR, uremic symptoms, or sometimes hyperkalemia or heart failure/
Transplantation.
2. Rp.: Tab. Prednisoloni 0,005 N 20.
D.S. 6 pills - 8 a.m., 4 pills -12 p.m., 2 pills-14 p.m. after meal.
Rp.: Tab. Captoprili 0,05 N 20
D.S. по 1 т. 3 раза в день
Rp: Tab. Dipyridamoli 0,025 №100
D.S. 3 tab 4 times daily
Typical task 28
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 in palpation. Urine analysis: Relative density - 1026, protein 1,2 g/L, er. - 25-27 ina field of vision, leukocytes 10-12, epithelial- plenty squamous epithelium, salts – oxylates. Ultrasound investigation of kidneys: echo structure is not homogenous, presence of multiple echo- contrast formations of 2-4 mm in calyxes and pelvis of both kidneys, diameter 7-8 mm in the middle third of right ureter.X-ray: absence of contrast secretion from the right ureter.
Diagnosis: urolithiasis, exacerbation. Right side renal colic.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 28.
1. Analgesia-- renal colic may be relieved with opioids, such as morphine and, for a rapid onset, fentanyl. Ketorolac 30 mg IV is rapidly effective and nonsedating.
Facilitate calculus passage (eg, with α-receptor blockers or Ca channel blockers)
For persistent or infection-causing calculi, removal using extracorporeal shock wave lithotripsy or endoscopic techniques
2. Rp: Sol. Drotaverini 2 ml
D.t.d. N 6 in amp.
S. 2 ml 3-4 times a day i/m
Rp.: Sol.Morphini hydrochloridi 1% - 1ml
D.t.d. N 6 in amp.
S. 1 ml subcutaneously
Typicaltask 29
The patient K, complaints of weakness, edema of the face and legs, enlargement of the abdomen, headache. Patient suffered from tonsillitis 2 months ago.
Objectively: paleness, edema, ascites, weakened vesicular breathing, heart sounds are arrhythmic, muffled, BP - 120/90 mm hg, anemia. Daily diuresis - 1260 ml, daily proteinuria - 5 g/l. General urine analysis: Relative density - 1026, protein 3,8 g /l, ery - 15-17, leukocytes 3-4, hyalinic casts - 8-10. Plasma albumin - 20 g/l, general protein - 58 g/l, lipids- 9,5 g/l, creatinine - 0,12 mmol/l, urea 8,9 mmol/l, glomerular filtration 91 ml/min.
Diagnosis: acute glomerulonephritis, nephrotic syndrome.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 29.
1. Angiotensin inhibition for hypertension or proteinuria
Corticosteroids (eg, prednisone 1 mg/kg po once/day or 2 mg/kg every other day) are recommended.
Cyclophosphamide and prednisone for active, potentially reversible nephritis
dipyridamole (225-450 mg po once/day) with aspirin (500 mg po once/day). Mycophenolale mofetil (500 mg to 1 g po bid) or azathioprine (2 mg/kg po once/day, maximum 150 to 200 mg/day).
An alternative is plasmapheresis with tacrolimus immunosuppression.
Na restriction (< 2 g Na, or about 100 mmol/day) is recommended for patients with symptomatic edema. Loop diuretics are usually required to control edema.
2. Rp.: Tab. Prednisoloni 0,005 N 20.
D.S. 6 pills - 8 a.m., 4 pills -12 p.m., 2 pills-14 p.m. after meal.
Rp.: Tab. Captoprili 0,05 N 20
D.S. по 1 т. 3 раза в день
Rp: Tab. Dipyridamoli 0,025 №100
D.S. 3 tab 4 times daily
Rp.: Enoxaparini 0,4 ml
D.t.d. № 5.
S. 0,4 ml 2 times a day subskin
Typical task 30
Female after longtime overcooling has complaints of painful urination, pain in the back region, fever,nausea and vomiting, headache, temperature 38,5°C, symptoms of tapotement is positive at both sides, palpation of kidneys is painful. Laboratory investigation: common blood analysis revealed neurophilic-eosinopenic reaction, daily proteinuria 0,5 g per day. Urine analysis: relative density - 1029, protein 0,08 g/l, leukocytes – 27-30. Salts – oxalates, expressible bacteriuria. Diagnosis: acute pyelonephritis.
Prescribe a treatment.
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№ 30.
1. Antibiotics: typical regimens are 14 days of TMP-SMX 160/800 mg po bid or fluoroquinolone (ciprofloxacin); ampicillin plus gentamicin, and broad-spectrum cephalosporins.
2. Rp: Ceftriaxone 1,0
D.t.d. № 20 in flac.
S. dissolve in the 4 ml of water for injection i/m 2 times a day
Rp: Tab. Levofloxacini 0,5 - №10
D.S. 1 tab once every 24 hours for 7–14 days
Typical task 31
Patient A., 18 -year-old, complains on fever (38°С) during 2 weeks, common weakness, gingival hemorrhage, hemorrhagic skin rash, sore throat at swallowing. Treatment with broad-spectrum antibiotics was noneffective.
Survey: height – 182 sm., weight – 80 kg, pallor, multiple bruises on the skin and mucosa, throat is hyperemic, necrotic tonsillitis, gingival hyperplasia. Bones are painful under palpation. CBC: pancytopenia, 35% of blast cells. Sternal puncture: 90% of blast cells sensitive to myeloperoxidase and lipids. Acute myeloid leukemia was identified.
Prescribe a treatment.
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№ 31.
1. Schema of polychemotherapy
*Induction of remission: 7+3: cytosar (cytosine, arabinoside, cytorabine) with rubomycin (daunorubicin).
Prophylaxis of neuroleukemia (intratecal injection of cytostatics).
Additionally:
Replacement therapy– thromboconcentrate, erythromass, granulocytic coloniostimulating factor (neipogen,leucomax) after course of polychimiotherapy.
*Consolidation of remission. Bone marrow transplantation.
2. Rp: Cytosar-arabinoside 0,1
D.t.d. N 10 in flac.
S. 1 flac. dissolved in 250 ml of 0,9 % solution of NaCl. IV infusion daily during 7 days.
Rp.: Tab.Prednisoloni 0,005 N 20
D.S. 6 tab.- at 8 o’clock in the morning, 4 tab.- in 12 o’clock., 2 tab.- in14 o’clock after meal.
Typical task 32
Patient K., 57 -year-old, suffers from chronic lymphatic leukemia, was on leukeran (chlorambucil) during two years with positive effect. Last time lymph nodes and spleen enlarge progressively. CBC: normochromic anemia (Hb – 85 g/l), leucocytosis 100 х 109/l, lymphocyte - 96%. III stage of disease was diagnosed.
Prescribe a treatment.
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№ 32.
1. 6-8 courses of polychemiotherapy according to the programme COP, CHOP, fludarabin+cyclophosphamide (depends from immunophenotyping of leukemic cells: В or Т).
Symptomatic therapy (erythromass transfusion, lymphocytapheresis, immune correction).
Additionally –radiation therapy, splenectomy, steam cells transplantation.
2. Rp: Cyclophosphamidi 0,2
D.t.d. N 10 in flac.
S. 1 flac. dissolved in 10ml of the water for injection.2 flac. IV infusion on 0,9% NaCl . from 1st to 5th days of course.
Rp: Fludara 0,05
D.t.d N 10 in flac.
S. 1 flac. dissolved in 2ml of the water for injection. IV infusion daily.
Typical task 33
Patient G., 22 -year-old, during 6 month feels progressive weakness, fatigue; dyspnea on exertion, epistaxis, gingival bleeding, and legs edema appeared.
Survey: pallor of skin and mucosa, peripheral lymph nodes are not enlarged, systolic murmur on the heart apex was determined. BP 120/80 mm.Hg; pulse rate 90 per min., vesicular respiration in lungs. Spleen, liver are not palpable.
CBC: Er.-2,1 х 1012/l, Hb – 64 g/l, reticulocyte – 0,1%, Pl.- 40 х 109/l, leukocytes – 2,4 х 109/l, stabs-2%, segm.-31%, lymph.-64%, mon-3%, ESR – 60 mm/h. Myelogram: Myelokaryocytes – 7,8 х 109/l, red row decreased (7%), megacaryocytes – few in the smear, thrombocytes discharging is not disturbed.
Hypoplastic anemia was diagnosed.
Prescribe a treatment.
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№ 33.
1. If glucocorticoids are not effective (prednisolone 1-2 mg/kg daily) during first 2 weeks of treatment, prescription of cyclosporine А (Sandimmun) and antylymphocytic or antythrombocytic globuline in association with coloniostimulating factor.
Additionally: erythromass transfusion in combination with desferal and thromboconcentrate, splenectomy. Bone marrow transplantation for the patient younger than 30 years old.
2. Rp.: Tab.Prednisoloni 0,005 N 20
D.S. 6 tab.- at 8 o’clock in the morning, 4 tab.- in 12 o’clock., 2 tab.- in 14 o’clock after meal.
Typical task 34
Patient A., 17 -year-old, suffering from hemophilia A needs surgical treatment of varicocele. In Anamnesis: formation of hematomas after trivial trauma, spontaneous hemarthrosis, prolonged bleeding which started 2-3 hours after tooth extraction.
Survey: knee, elbow joints defigurate, range of motions is limited to 10-15%, muscular hypotrophy in affected joints zone.
CBC is normal. Blood clotting time (Li-White test in trivial tube) – 18 min.; recalcification time – 300 sec.; APTT – (coaline – cephalin method) – 60 sec. All indices became normal after addition of fresh deprothrombinised plasma. Hemophilia A was diagnosed.
Prescribe a treatment.
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№ 34.
1. Before surgery we should increase serum level of factor VIII to 80-120%. Cryoprecipitate or factor VIII concentrate, FFP (10-15 ml/kg * 2-3times per day).
Inhibitors of fibrinolysis in case of trauma (aminocapronic or tranexamic acid).
2. Rp: Acidi aminocapronici 5%-100,0
D.t.d. N 3
S. 1 flac. dissolved in 200 ml of 0,9% solution of NaCl.
IV infusion during 15-30 min.
Typical task 35
Woman, 23 -year-old, presents with gingival hemorrhage, epistaxis, and bruise appearance one week after grippe. In anamnesis: bruise appearance after trivial trauma, metrorrhagia.
Survey: petechial skin rash, numerous bruises on the skin and mucosa. Other pathology was not revealed.
In CBC: platelets – few in the smear, other indices are in normal range. Bleeding time (Duke test) – 12 min. Blood clotting time (Li-White test) – 7 min. APTT – 44 sec.
Bone marrow: Myelokaryocytes – 170 x 109, leuko-erythroid ratio is 3:1, lot of megacaryocytes, formation of thrombocytes is not observed.
Idiopathic thrombocytopenic purpura was diagnosed.
Prescribe a treatment.
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№ 35.
1. Glucocorticoids- prednisolone 1-2 mg/kg.
If it’s no response- splenectomy (at 4-5 years old patient).
Cytostatic therapy (azathyoprin, cyclophosphamide).
2. Rp.: Tab.Prednisoloni 0,005
D.t.d. N 100
S. 6 tab.- at 8 o’clock in the morning, 4 tab.- in 12 o’clock., 2 tab.- in14 o’clock after meal.
Rp: Cyclophosphamidi 0,2
D.t.d. N 10 in flac.
S. 1 flac. dissolved in 10ml of the water for injection.2 flac. IV infusion on 0,9% NaCl . from 1st to 5th days of course.
Typical task 36
A 36-year-old female was admitted to surgical department with supposed abdominal emergencies. She complains on spastic pain in abdominal area, increased temperature (38-38.538 °С), pain in joints.
Survey: pallor of the skin, peripheral lymph nodes are slightly enlarged, swelling of the skin under large joints, symmetric petechial skin rash on the legs and anterior abdominal wall. Palpation of abdominal area is painful under caecum and sigmoid colon, colon is spastic.
CBC: moderate neutrophilic-eosinophilic leucocytosis, ESR – 45 mm/h. Urine analysis: DI – 1018, protein – 0,99 g/l, Leuk. – 2-4; Er. – 40-50 in the field of vision, hyaline and granular cylinders. Sialic acid – 890 mg/l , C-reactive protein +++, fibrinogen A – 6 g/l.
Henoch-Schönlein purpura was diagnosed.
Prescribe a treatment.
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№ 36.
1. Heparin 300-400 IU/kg with glucocorticoids or NSAIDS. Prednisolone 0,5-2 mg/kg. If it’s not effective cytostatic therapy (azathyoprin, cyclophosphamide) should prescribe. Plasmapheresis.
2. Rp: Sol. Heparini 25 000 IU
D.t.d. N 4 in flac.
S. 5000 IU s/c each 6 hours.
Rp.: Tab.Prednisoloni 0,005 N 20
D.S. 6 tab.- at 8 o’clock in the morning, 4 tab.- in 12 o’clock., 2 tab.- in14 o’clock after meal.
Rp: Cyclophosphamidi 0,2
D.t.d. N 10 in flac.
S. 1 flac. dissolved in 10ml of the water for injection.2 flac. IV infusion on 0,9% NaCl . from 1st to 5th days of course
Typical task 37
The patient of 43 years, complaints on bad appetite, nausea, bloating and a rumbling in abdomen after eating, heaviness in the right hypochondrium, weakness, rapid fatiguability. 10 years ago viral hepatitis type C was diagnosed.
Physical examination: the patient is emaciated; skin and visible mucous membrane are icteric, edema of the lower extremities, teleangiectasia. The abdomen is enlarged, the phlebectasia of a front abdominal wall (“caput medusae”), ascites are observed. The liver is dense, nodular, painless, enlarged. Splenomegaly.
Laboratory data: general bilirubin 54,4 mmol/l; direct 22,2 mmol/l, indirect 32,2 mmol/l; AST - 3,61 mmol/l/h; АLТ - 2,12 mmol/l/h, albumine - 23 g/l, prothrombin index - 54 %. Ultrasonic examination reveals enlarge of a liver, echostructure is diffusely heterogeneous, dense, dilating of portal and splenic veins, ascites.
Cirrhosis was diagnosed.
Prescribe a treatment.
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№ 37.
1. Diet 5.
Antiviral therapy:
*Interferontherapy (pegIntron, Intron).
*Nucleosid’s analogs (ribavirin, lamivudin).
Vit.С, polyvitamines. Detoxication (rheososbilact, enterosorbtion – enterodes). Lactulose (dufalac). Diuretics (spironolactone, furosemide).
Laparocentesis. Liver transplantation.
2.a) Rp: Intron A 5 mln. IU
D.t.d. in flac. N 10
S. 1 flac. dissolved in 1ml of the water for injection, IM daily.
b) Rp: Ribavirin 0,2 in caps. N 30
D.S. 1 caps. 2 t/d after meal.
c) Rp: Siropus Dufalaci 200 ml
D.S. 30 ml 3 t/d during meal.
Typical task 38
The patient of 38 years complains on weakness, rapid fatigability, lose of weight, discomfort and heaviness in the right hypochondrium increased after rich food, periodic rise in temperature up to 37,50 С . 5 years ago viral hepatitis type B has been diagnosed. Physical examination: skin and visible mucous membrane are usual colour. The abdomen is soft, slightly painful in epigastrium and the right hypochondrium. The liver is extended 3 cm below the costal arch, dense, rounded, gently painful at palpation. The lien is not enlarged. The general bilirubin - 30,7 mmol/l; direct - 16,2 mmol/l, indirect - 14,5 mmol/l. AST - 4,13 mmol/l; АLТ - 4,82 mmol/l. HbsAg, HbeAg and HBcAb - positive.
Prescribe a treatment.
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№ 38.
1. Diet 5.
Interferontherapy (laferone, pegIntron,).
Nucleosid’s analogs (ribaverin, lamivudin). Vit.С, polyvitamines. Detoxication (rheososbilact, enterosorbtion – enterodes). Lactulose (dufalac). Hepatoprotectors (essentiale). Vit.С, polyvitamines. Metabolites (cocarboxilase, thiotriasoline).
2. a) Rp.: Intron A 5 mln. IU
D.t.d. N 10 in flac..
S. 1 flac. dissolved in 1ml of the water for injection, IM daily.
b) Rp: Ribavirin 0,2 in caps. N 30
D.S. 1 caps. 2 t/d after meal.
c) Rp: Sol. Essentiale 5 ml
D.t.d N5 in amp.
S. 5 ml IV dissolving in autoblood, ratio 1:1
Typical task 39
Woman, 49 years old, has Scleroderma. Clinical presentation: subcutaneous calcifications occur mostly in the hands and near bone eminences, Raynaud's syndrome, difficulty at swallowing, sclerodactylia, teleangiectases in the distal surface of upper extremities and face. T 36.80 C,
CBC: Er. – 4,4*1012/l, Hb – 140 g/l, L. – 8 *109/l, ESR – 15 mm/h., C-reactive protein (-).
Urine analyses – proteinuria 0.034 g/l, L. – 2-3 in a field of vision, Er. – 2-3 in a field of vision.
Prescribe a treatment.
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№ 39.
1. Antifibrosive drugs (D-penicillamine), NSAIDs, aminochinolones (chlorochine), for microcirculation’s improvement- Са channel blockers, antiagregants, prostaglandins. Local therapy.
2. Rp: Tab. Amlodipini 0,010 N 28
D.S. 1/2 tab. 1-2 times per day.
Rp. Tab. Ac. Acetylsalicilici 0,1
D.S. 1 tab. 1 t/d after meal.
Typical task 40
Woman 49 years old has fever 40,00C, “butterfly” facial erythema, symmetric arthritis of small joints of upper extremity.
CBC: Er. – 2,5*1012/l, Hb – 85 g/l, Tr. - 180*109/l, L. – 4*109/l, ESR – 32 mm/h. Urine analyses – proteinuria 1.53 g/l, L. – 2-3 in a field of vision, Er. – 7-10 in a field of vision. Coombs' test positive, C – reactive protein +++, anti-DNA antibodies +, SLE-cells +.
Systemic lupus erythematosus was diagnosed.
Prescribe a treatment.
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№ 40.
1.Diet №7
Prednisolone 1mg/kg in the first half a day. Dexamethasone.
Cytostatics (azathyoprine 50 mg).
Plasmapheresis, hemosorbtion.
Antiagregants, anticoagulants (dypiridamole, heparin).
Rp.: Tab.Prednisoloni 0,005 N 20
D.S. 6 tab.- at 8 o’clock in the morning, 4 tab.- in 12 o’clock., 2 tab.- in14 o’clock after meal.
Rp.: Tab. Azathloprini 0,05 N 50
D.S. 1 mg/kg a day.
Rp: Sol. Heparini 25 000 IU
D.t.d. N 4 in flac.
S. 5000 IU s/c each 6 hours.
Typical task 41
A 58 year-old man complained of pain and swelling of the left foot small joints. For the last 6 years he has had a few episodes of such arthritis with duration of each one up to 7 – 10 days. On examination, the skin over these joints was purple, body temperature - 38°C. A body temperature - 38,80С. In blood - 9,6*10 9/l, neutrophils - 74 %, ESR - 30 mm/h. Uric acid 0,580 mmol/l. Gout was diagnosed.
Prescribe a treatment.
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№ 41.
1. For the treatment of acute gouty arthritis appointed colchicine, NSAIDs (indomethacin, diclofenac, selective inhibitors of cyclooxygenase-2).
After the relief of acute events assigned long-term therapy: normalization of body weight, diet № 6 (exclude Savoury, meat, oily fish, meats, canned beans, peas, sorrel, alcohol), hypouricemic therapy (allopurinol).
2. Rp: Tab. Colchicini 0,001 № 10
D.S. On 1 tab. 3-6 times a day with an acute attack of gout
Rp: Tab. Diclofenaci-natrii 0,025 №10
D.S. On 1 tab. 3-4 times daily after meals
Typical task 42
A 19-year-old girl admitted to the hospital complained of pain in the knee and fever of 38.6°C. She fell ill after 2 weeks after suffering acute tonsillitis. On examination, hyperemia and swelling of both knees, body temperature - 37.4°C, HR of 94/min, BP of 120/80 mm Hg, heart border is displaced to the left; S1 is weak, systolic murmur is present. Total blood count shows the following: Hb – 120 g/L, WBC – 9.8•109/L, ESR of 30 mm/L. ECG findings: the rhythm is regular, PQ = 0.24 sec. Antistreptolysine-О - 1:500000. Acute rheumatic fever was diagnosed.
Prescribe a treatment.
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№ 42.
1. Etiologic treatment - penicillin to 8 000 U per day for 10 days. Pathogenetic - NSAIDs (indomethacin, diclofenac, selective inhibitors of cyclooxygenase-2 - nimesulide 10 mg / day), glucocorticoids - prednisolone 20 mg / day, and antihistamines. Symptomatic treatment.
2. Rp: Tab. Meloxicami 0,015 № 20
D.S. 1 tablet 1-2 times daily with meals.
Rp: Sol. Benzylpenicillini sodii 500000 U
D.t.d. № 10 in amp.
S. By 1000000 U 4 times a day i/m
Rp: Tab. Prednisoloni 0,005 № 100
D.S. 4 tablets morning 2 tablets the day
Typical task 43
A man of 57 years old works more than 7 years on silicon ore mines. He complains on the breathlessness during the physical exertion, indefinite pain in the chest, cough with a little secretion of sputum. Auscultation: respiration is weak, dry rales. Functional parameters — increased residual lung volume, decreased vital capacity of lungs (50-80%). X-ray: diffusely increased vascularization, enlarged roots, diffuse sclerosis, nodular shadows 3-4 mm in diameter are revealed. Silicosis was diagnosed.
Prescribe a treatment.
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№ 43.
1. Radical method of treatment is absent. Avoid contact with dust. Transfer to another job without contact with dust. Oxygen therapy for improving pulmonary ventilation. Purine derivatives - aminophylline, theophylline. Mucolytics - Ambroxol, Bromhexine, N-acetyl cysteine. Increase in the overall resistance of the body, spa treatment, a balanced diet
2. Rp.: Tab. Ambroxoli hydrochloridi 0,03 № 20
D. S. 1tablet 3 times a day.
Rp.: Tab. Theophyllini 0,3 № 15
D. S. 1tablet 2 times a day.
Typical task 44
A 30 y.o. man complains of epigastric pain, nausea, periodical heartburn and constipation. He was sick for 2 years with exacerbation in the spring time. On palpation there are moderate tenderness and increased sensitivity in epigastric area. EGDS shows antral gastritis, pH-metry 1,2, CLO-test +++. The diagnosis of chronic gastritis associated with Helicobacter pylori was established.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 44.
1. H. pylori therapy (proton pump inhibitor - omeprazole 20 mg 2 times a day + amoxicillin 1000 mg 2 times a day + clarithromycin 500 mg 2 times a day or a proton pump inhibitor + De-nol 120 mg 4 times daily + tetracycline 500 mg 4 times daily + metronidazole 500 mg 3 times daily), antisecretory drugs (proton pump inhibitors - omeprazole, pantoprazole, lanzoprazole) and H2-histamine blockers (ranitidine, famotidine), a selective M-anticholinergics - gastrotsepin)) , antacids - Maalox, almagel, prokinetics - metoclopramide, domperidone, cisapride).
2. Rp: Caps. Omeprasoli 0,02 № 30
D.S. Take 1 caps. 2 times a day for 30 minutes. before meals
Rp.: Tab. Clarithromycini 0,5 № 14
D.S. Take 1 tablet. 2 times a day.
Rp.: Tab. Amoxicillini 1,0 № 20
D.S. Take 1 tablet. 2 times a day.
Rp.: Tab. Domperidoni 0,01 № 10
D.S. Take 1 tablet. 3 times a day for 30 minutes before meals.
Typical task 45
A 45 y.o. man complains of dull pain in epigastric area, which disappear after meal, “night” pain, nausea, heartburn. Anamnesis: it was established that he had been treated 2 years ago in gastroenterological department with diagnosis: ulcer of duodenum. Endoscopy showed ulcerative defect and erosions in duodenal bulbus. 13C-urease breath test was positive. Diagnosis is ulcer disease of duodenum, active phase, Helicobacter pylori-associative.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 45.
1. H. pylori therapy (proton pump inhibitor - omeprazole 20 mg 2 times a day + amoxicillin 1000 mg 2 times a day + clarithromycin 500 mg 2 times a day or a proton pump inhibitor + De-nol 120 mg 4 times daily + tetracycline 500 mg 4 times daily + metronidazole 500 mg 3 times daily), antisecretory drugs (proton pump inhibitors - omeprazole, pantoprazole, lanzoprazole) and H2-histamine blockers (ranitidine, famotidine), a selective M-anticholinergics - gastrotsepin)) , antacids - Maalox, almagel, prokinetics - metoclopramide, domperidone, cisapride).
2. Rp: Tab. Pantoprazoli 0,04 № 10
D.S. Take 1 tablet 1 time a day.
Rp.: Tab. Amoxicillini 1,0 № 20
D.S. Take 1 tablet 2 times a day.
Rp.: Tab. Clarithromycini 0,5 № 14
D.S. Take 1 tablet. 2 times a day.
Rp.: Susp. “Maalox” 250 ml № 1
D.S. 15 ml 4-5 times a day
Typical task 46
A 36 y.o. woman suffered from pain in epigastric and umbilical areas, meteorism, distention of abdomen, which relieve after defecation, constipation. These symptoms appeared more than three months ago. Laboratory tests and instrumental examination showed no pathological changes. Diagnosis of irritable bowel syndrome was determined.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 46.
1. Prokinetics - metoclopramide, domperidone, cisapride, a diet rich in fiber, laxatives, if necessary (lactulose, mukofalk), sedatives and antidepressants, antispasmodics - meteospazmin, no-spa.
2. Rp: Sol. "Guttalax" 30 ml
D.S. Take 10-12 drops at night.
Rp.: Tab. Domperidoni 0,01 № 10
D.S. Take 1 tablet. 3 times a day for 30 minutes before meals.
Rp: Sol. Drotaverini 2 ml in amp. № 10
D.S. 2 ml 3-4 times a day i/m
Typical task 47
A 42 y.o. woman suffered from nonspecific ulcerative colitis during 3 years. She has pain in the lower part of abdomen, diarrhea with blood, fever. On rectoscopy there is inflammatory process in sigmoid with superficial ulcers, pseudopolyps, hyperemia, oedema. In blood: Hb-102 g/l, RBC 3,1*1012/l ,WBC 10,3*109/l , ERS 30 mm/h. In feces: erythrocytes, leucocytes, mucous in large quantities.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 47.
1. Sulfasalazine, mesalazane - 2-4 grams per day, prednisolone - 20-40 mg per day, antispasmodics (meteospazmin, Buscopan, no-spa), prokinetics (metoclopramide, domperidone, cisapride), azathioprine - 2-2,5 mg / kg, antidiarrheal (Imodium), if need - antibacterials (metronidazole, tinidazole).
2. Rp.: Tab. Sulfasalasini 0,5 № 100
D.S. Take 1 tablet. 3 times a day.
Rp: Prednisoloni 0,005
D.t.d. № 100 in tab.
S. 8 tablets morning 4 tablets the day
Rp: Loperamidi 0,002
D.t.d. № 30 in tab.
S. 2 tablets 2 times a day
Typical task 48
A 45 y.o. woman complains of periodical pain in right hypochondrium after fatty meal, nausea, bitter taste in the mouth, constipation. On physical examination obesity, painful palpation in the right hypochondrium area was founded. In sonography of hepatobiliary system was revealed the enlarged gallbladder with thick walls and 3 small (<20 mm) stones were determined. The diagnosis is cholelithiasis, chronic cholecyctitis.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 48.
1. On indications - litholytic therapy - ursodeoxycholic acid on 0,5-1 g at bedtime, antispasmodics (Buscopan, no-spa, duspatalin), prokinetics (domperidone, cisapride), antibiotic therapy when indicated, diet № 5
2. Rp: Mebeverinii 0,02 № 30 in caps.
D.S. Take 1 tablets. for pain.
Rp.: Caps. Acidi ursodeoxycholici 0,25 № 50
D.S. Take 3 capsules. at night
Rp: Ceftriaxoni 1,0 № 10 in flac.
D.S.Dilute 4 ml water for injections intramuscularly 2 times a day
Typical task 49
A 54 y.o man suffered from chronic pancreatitis during 7 years. He complains of dull pain in epigastric and left hypochondrium areas, mostly after fatty meal and alcohol intake, nausea, periodical vomiting, diarrhea. On physical examination, painful palpation in epigastric and left hypochondrium areas was determined. US-scan of abdomen shows enlarged pancreas with signs of fibrosis and calcification. In feces analysis undigested muscle fibers and fat. Diagnosis: chronic pancreatitis, exocrine pancreatic insufficiency.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 49.
1. Antispasmodics (Buscopan, no-spa, baralgin), proton pump inhibitors (pantoprazole, rabeprazole, lazoprazol) and H2-histamine blockers (ranitidine, famotidine), somatostatin - 250 mg per day, Replacement therapy - Creon, pangrol, festal.
2. Rp: Caps. “Creon 10000” 0,3 № 50
D.S. Take 1 tablet 3-4 times a day during meals
Rp: Caps. Lansoprazoli 0,03 № 20
D.S. Take 1 caps. 2 times a day for 30 minutes before meals.
Rp: Sol. Baralgini 5,0 № 5
D.S. To 5 ml by intravenous very slow.
Typical task 50
A 34 y.o. man complains of jaundice, skin itching, discomfort in epigastric and right hypochondrium areas, bad appetite, loss of weight, fever, pain in joints. On physical examination yellow discoloration of skin and sclera, enlarged and painful liver (+5 cm). T 37,8*C. The blood analysis revealed total billirubin 89 mmol/l, direct 61 mmol/l, AST 2,3, ALT 1,9, alkaline phosphotase 4,2 mmol/l, cholesterol 8,7 mmol/l, viral hepatitis markers are negative, antimitochondreal and antinuclear antibodies was founded. Diagnosis: chronic autoimmune hepatitis, cholestatic syndrome.
Prescribe a treatment.
Write down the receipts for most commonly used drugs.
№ 50.
1. Prednisolone 30-40 mg daily, azathioprine 50 mg / day, cholestyramine, ursodeoxycholic acid, hepatoprotectors - silymarin containing hepatoprotectors (silibor, gepabene), essential phospholipids (Essentiale)
2. Rp: Caps. "Essentiale" № 100
D.S. Take 2 caps. 3 times a day.
Rp: Prednisoloni 0,005
D.t.d. № 100 in tab.
S. 4 tablets morning 2 tablets the day
Rp.: Caps.”Ursofalk” 0,25 № 50
D.S. Take 1 caps. morning and afternoon, and 2 caps. at night
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