Therapy Flashcards
Task 64
A 21-year-old patient called a doctor to the house urgently due to complaints of a large amount of scarlet blood from the rectum during bowel movements , frequent stools up to 5 times a day, an increase in body temperature to 38 ° C, general weakness.
The appearance of blood in the stool was noted during the last 2 months , the stool gradually began to become more frequent, the consistency changed to mushy, there was general weakness, low-grade fever, deterioration within 3 days.
On examination, the skin is pale.
BP - 110/70 mm Hg. Art. Pulse - 96 per minute, rhythmic. The tongue is coated with a white coating.
The abdomen is soft, painful in the left iliac region . Symptoms of peritoneal irritation are negative.
The patient was sent to a hospital for the selection of therapy and further examination in order to clarify the diagnosis.
The task
1. Formulate a preliminary diagnosis.
2. With what diseases is it necessary to carry out a differential diagnosis?
3. What research needs to be done for this patient?
4. What groups of drugs can be used to treat this patient?
5. What are the possible complications of this disease?
1:Diagnosis -Ulcerative colitis, proctosigmoiditis, moderate attack.
2: differential diagnosis includes:ischemic colitis ,acute dysentery , Crohn’s disease, pseudomembranous colitis,hemorrhoids
3:research needs; General blood test, b / x blood test (glucose, cholesterol, lipids, K, Na, Ca, protein and fractions, (anemia:decreased red blood cells ,CRP, alkaline phosphatase, GGTP, bilirubin, amylase, creatinine),
* coprogram, general urine analysis, fecal calprotectin, ANCA, ASCA, toxin A / B,
* calcium;
*Fecal calprotectin (↑100 mcg/g).
stool culture for dysbiosis , RNGA with pseudotuberculosis antigen , yersiniosis antigen
* ultrasound of the abdominal cavity, EFGDS, fibrocolonoscopy + intestinal biopsy.
*X-ray
4: treatment; 1. Depending on the degree of inflammation . 5-Ask (mesalazine) preparations, - 0.5-1.0 g tablets and local therapy proctitis(mesalazine in candles or
Left sided colitis (Mesalazine in enemas (salofalk 2 grams 1-2 times a day
For moderate course we prescribe prednisone 0.005 initially 40-60 mg a day 10 to 14 days improvement before gradual reduction of 10mg of prednisone
( Prednisolone, Budesonide ) in enemas (budesonide )systemic and local - rectally, for complicated course of the disease we use cytostatics (Metatrexate 25mg + folic acid to prevent side effects , Azathioprine 2-3mg per kg of patients weight ).
Genetically engineered biological therapy. Symptomatic: antispasmodics, intestinal antiseptics, probiotics.
Bowel perforation, sepsis,
** Additional information
- The preliminary diagnosis for this patient is acute lower gastrointestinal bleeding, likely caused by inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn’s disease, given the symptoms of rectal bleeding, frequent stools, and abdominal pain.
- Differential diagnosis for this clinical case includes:
- Infectious colitis
- Ischemic colitis
- Diverticulitis
- Colorectal cancer
- Hemorrhoids
- Anal fissures - Research that needs to be done for this patient includes a colonoscopy or sigmoidoscopy to visualize the colon and rectum and identify the source of bleeding, as well as laboratory tests to assess the patient’s blood count and inflammatory markers.
- Drugs that can be used to treat this patient include anti-inflammatory medications, such as corticosteroids and mesalamine, to reduce inflammation in the colon and rectum, as well as antibiotics if there is evidence of infection. Iron supplements may also be necessary to address anemia caused by bleeding.
- Possible complications of IBD include severe bleeding, bowel obstruction, and the formation of abscesses or fistulas. In some cases, IBD can also increase the risk of developing colorectal cancer.
Task 65
Patient K., 29 years old, consulted a local general practitioner with complaints of frequent weak aching pains in the epigastric region , which decrease after eating; feeling of quick satiety; sour belching. Also notes general weakness, instability of the stool.
These complaints periodically bother over the past 5 years, the current deterioration in health - 1.5 weeks ago.
He took antacids on his own with a short-term positive effect .
On objective examination: the condition is satisfactory. Skin and visible mucous membranes of normal color, clean. On the part of the cardiovascular, respiratory systems without features. The tongue is moist, coated with a white coating. The abdomen is of normal shape, soft on palpation, painful in the epigastric region.
In the clinical analysis of blood: erythrocytes - 4.8 × 10 12 / l, hemoglobin - 140 g / l, CP - 0.87, platelets - 380 × 10 9 / l, leukocytes - 7.2 × 10 9 / l, ESR - 16 mm / h.
In a biochemical blood test: ALT - 21 U / L, AST - 18 U / L, amylase - 53 U / L, alkaline phosphatase
- 78 U / l.
FGDS performed: there is a large amount of mucus in the lumen of the stomach. Phenomena of moderate atrophy in the pyloric region of the stomach, edema and hyperemia in the fundus of the stomach . Active peristalsis. The stomach expands well with air.
H.pylori test +++.
The task
1. Formulate the most likely diagnosis.
2. Is there a need for eradication therapy in this case?
3. Suggest a treatment plan.
4. What factors of natural protection of the gastric mucosa and factors of aggression do you know?
5. What complications of this disease are possible in the absence of specific treatment?
1: Diagnosis Chronic atrophic gastritis, HP-associated, exacerbation phase. Functional dyspepsia.
2: The presence of zones of atrophy in HP- associated gastritis is an indication for mandatory eradication therapy, since this is a preventive measure to prevent precancerous changes in the gastric mucosa and cancer itself.
3:treatment: Sparing diet, table number 1.
-Triple regimen of eradication therapy, which includes PPIs-rabeprazole 20mg (in a standard dose 2 times a day) + Clarithromycin (500 mg 2 times a day) + Amoxicillin (1000 mg 2 times a day) for 10-14 days
Or
- A four-component regimen based on Bismuth tripotassium dicitrate (120 mg 4 times a day) in combination with PPIs (in a standard dose 2 times a day), Tetracycline (500 mg 4 times a day), Metronidazole (500 mg 3 times a day) within 10 days ;
- prokinetics (Domperidone 10mg orally 3-4 times a day ) to eliminate the symptoms of functional dyspepsia; probiotics
4: A) Factors of aggression : hydrochloric acid, pepsin, violation of the evacuation function of the stomach, duodeno-gastric reflux, HP infection;
B) factors of protection of the mucous membrane : mucus formation, secretion of bicarbonates, proper blood flow, regeneration of the epithelium, prostaglandins, immune defense.
5 complications:Persistence of HP infection can lead to the formation of mucosal ulcers, complicated by bleeding, perforation, penetration into neighboring organs, the formation of cicatricial deformities, and malignancy.
With atrophy of the gastric mucosa due to HP infection, it can be replaced by intestinal epithelium (metaplasia), and then epithelial neoplasia.
Bleeding
***
Additional information
- The most likely diagnosis for this patient is chronic gastritis, likely caused by H. pylori infection, given the symptoms of epigastric pain, sour belching, and atrophy in the pyloric region of the stomach seen on FGDS.
- Yes, there is a need for eradication therapy in this case as the H. pylori test was positive. H. pylori infection is a common cause of chronic gastritis and can lead to complications such as peptic ulcers and gastric cancer if left untreated.
- The treatment plan for this patient should include a course of antibiotics to eradicate the H. pylori infection, along with proton pump inhibitors to reduce gastric acid secretion and promote healing of the gastric mucosa. The patient should also be advised to avoid alcohol, spicy foods, and other irritants that can exacerbate gastritis symptoms.
- Factors of natural protection of the gastric mucosa include the mucus layer, bicarbonate secretion, and blood flow to the gastric mucosa. Factors of aggression include H. pylori infection, NSAID use, alcohol consumption, and stress.
- Possible complications of chronic gastritis in the absence of specific treatment include peptic ulcers, gastric bleeding, and gastric cancer. Eradication of H. pylori infection can help prevent these complications and improve the patient’s overall prognosis.
Task 41
Patient K., 50 years old, turned to the local doctor in connection with the first attack of heartbeat, accompanied by muscle tremors, weakness, slight difficulty in breathing . The attack occurred about 2 hours ago with severe emotional stress. Previously, with regular medical examination, no diseases were detected, blood pressure was always within normal limits. Previously taken ECG showed no pathological changes. She tolerates very significant physical activity well.
On examination: clear consciousness. The skin is of normal color and moisture. In the lungs, vesicular breathing, RR - 18 per minute. The boundaries of relative cardiac dullness are within normal limits. Arrhythmic heart sounds, no murmurs, heart rate - 144 beats per minute, pulse - 108 per minute. BP - 130/80 mm Hg. Art. The liver is not enlarged.
There are no peripheral edema. Body temperature 36.9 ° C.
Presented ECG lead II (speed 25 mm / s):
The task
1. Suggest the most likely diagnosis.
2. What are the deviations from the norm, visible on the presented ECG, and formulate an ECG-conclusion.
3. What syndrome is the leading one in the clinical picture of this disease?
4. Among what similar conditions are differential diagnostics required?
5. With the introduction of what drugs should you begin to relieve this emergency?
1:Diagnosis : Atrial fibrillation (Idiopathic paroxysmal atrial fibrillation, tachysystole, hemodynamically insignificant par-
oxysm.) Stage 2A
2: The axis is deflected to the left, (looking at Lead 1 and AVF = lead 1 QRS complex is positive and negative in avF
-the rhythm is non-sinus
- atrial fibrillation (there is no p wave ,
-different rr intervals,
-there are f waves).
Paroxysmal form of FP, unclear etiology.
3:The leading syndrome is rhythm disturbances .
4:differential diagnosis: - among FPs by etiology; with other tachyarrhythmias (for example, atrial flutter , mb with a stretch sinus tachycardia, paroxysmal supraventricular tachycardia - but there the rhythm is correct and there are no f waves)
5: The attack lasts less than 48 hours, we restore the rhythm - we inject heparin 5000 iu and an antiarrhythmic (if there is no organic damage to the heart - propafenone, procainamide). Our patient can use propafenone, 300-600 mg.
*Edoxaban 60mg once daily
*You can amiodarone 300-400 mg drip in glucose 500 dangerous by the development of blockages).
If it was more than 48 hours, they would give AK (Applied kinesiology (AK) for 3 weeks, and then restore the rhythm (HP / electro), and then again AK therapy with the possibility of long-term use (if there is a risk of TE)
* Next, the patient is referred to a local therapist, it is necessary to calculate the risk of thromboembolic complications and bleeding in order to resolve the issue of prescribing anticoagulants .
This patient does not need, does not score 2 points for the appointment of AK. Optional: if persistent or persistent FFP
Heart rate control is very important (avoid tachysystole): beta-blockers or nondihydropyridine ACCs (verapamil, diltiazem).
Very rare - amiodarone.
We also calculate the risk of thromboembolic complications and, if necessary, AK therapy. 1. CHERNOGORIUK
Paroxysmal atrial fibrillation
1. The most likely diagnosis for this patient is paroxysmal supraventricular tachycardia (PSVT), given the symptoms of sudden onset of palpitations, muscle tremors, and weakness, as well as the arrhythmic heart sounds and rapid heart rate seen on examination.
2. The ECG shows a narrow QRS complex tachycardia with a regular rhythm and a heart rate of approximately 144 beats per minute. There are no visible P waves, indicating that the tachycardia is likely originating from a site above the ventricles, such as the atria or the AV node. The ECG conclusion would be “Narrow complex tachycardia consistent with PSVT.”
3. The leading syndrome in the clinical picture of PSVT is palpitations, which can be accompanied by other symptoms such as weakness, dizziness, and shortness of breath.
4. Differential diagnosis for PSVT includes other types of supraventricular tachycardia, such as atrial fibrillation or atrial flutter, as well as ventricular tachycardia.
5. The introduction of drugs to relieve this emergency should begin with vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, to try to slow the heart rate. If these maneuvers are not effective, adenosine can be administered intravenously to interrupt the reentry circuit responsible for PSVT. Calcium channel blockers or beta-blockers may also be used to prevent future episodes of PSVT. In severe cases, electrical cardioversion may be necessary to restore normal sinus rhythm.
Task 42
A 42-year-old man has come to the clinic with an attack of intense constricting pain behind the sternum without clear radiation, accompanied by nausea, profuse sweating, and dyspnea. By the time the patient came to the clinic, the attack had been continuing for about 3 hours. The patient has been smoking for many years, 10-15 cigarettes a day.
There is no history of arterial hypertension or other cardiovascular diseases, diabetes, neurological disorders, head trauma, coagulopathy and severe bleeding.
The patient’s consciousness is clear. The skin is pale, hyperhidrosis. Respiration is vesicular, without rale. Respiration rate is 18 brpm. Cardiac sounds are rhythmic. Heart rate is 90 bpm, arterial pressure is 130/80 mmHg. The abdomen is soft and painless in all regions. The liver is not enlarged.
ECG was urgently taken.
Task
1. Suppose the most likely diagnosis.
2. What abnormalities are visible on the given ECG? Present an ECG report.
3. What is the treatment plan of the general practitioner in this situation?
4. What medical emergencies should differential diagnosis be carried out with? 5. What laboratory markers should be used to confirm the diagnosis?
1.Diagnosis: Arteriosclerotic heart disease: acute transmural anterior extensive myocardial infarction,
acute phase. Killip class I based on the classification by T. Killip, J. Kimball.heart failure class 1(no evidence of heart failure)
2.ECG abnormalities include
*ST segment elevation is visible in leads v2,v3,v4,v5indicating acute myocardial infarction on the anterior heart
3.Treatment plan
* Emergency hospitalization. Before the arrival of the ambulance team:
###start drug therapy 1st step then consider revascularization
>oxygen
>morphine
>aspirin 325mg
>Nitrates
>Beta blockers
>Heparin
##consider clopidogrel 300-600mg or prasugrel 60mg if PCI is indicated
Our patient STEMI thus we should immediately transfer the patient to a cardiology facility and PCI is indicated within 90min and begin urgently angiography,then if coronary artery is amenable proceed to PCI I,and if it’s not amenable proceed to Emergency CABG(coronary artery bypass surgery)
##If PCI is not done within 90mins proceed to thrombolytic therapy with Atepelase ,if there is still persistent ischemia repeat thrombolytic therapy or do PCI if available but if no persistent ischemia you can do elective PCI within 24-72 hrs
###Post acute coronary syndrome do the following
>management of risk factors such as hypertension,diabetes,diet,sedentary lifestyle,obesity,smoking
>prescription of drugs like AcE inhibitors,clopidogrel 75mg once day ,maximum tolerated statin dose
* put the patient to bed, install a bedside cardiac monitor (if possible), anesthesia (Nitroglycerin 0.6mg sublingual - nitrospray or non-narcotic analgesic - ketorol 10 mg IM +morphine ) , chew aspirin 500 mg , clopidogrel 300 mg , heparin 5000 ME therapy - heparin PC. Ace inhibitors
4. Differential diagnosis
* Newly onset angina pectoris,
* acute pericarditis
* dissecting aortic aneurysm,
* pulmonary embolism
5. Laboratory markers of myocardial infarction
* Creatine-Kinase-MB isoform
* Cardiac Troponin T and I
** Additional information
- The most likely diagnosis for this patient is acute coronary syndrome (ACS), specifically an ST-elevation myocardial infarction (STEMI), given the symptoms of intense chest pain, nausea, sweating, and dyspnea, as well as the patient’s history of smoking.
- The ECG shows ST-segment elevation in leads II, III, and aVF, indicating an inferior wall STEMI. The ECG report would be “Inferior wall STEMI with ST-segment elevation in leads II, III, and aVF.”
- The treatment plan for the general practitioner in this situation should include immediate transfer of the patient to a hospital for urgent reperfusion therapy, such as percutaneous coronary intervention (PCI) or thrombolytic therapy. The patient should also be given aspirin and nitroglycerin to help relieve symptoms.
- Differential diagnosis for ACS includes unstable angina and non-ST elevation myocardial infarction (NSTEMI), as well as other conditions that can cause chest pain, such as pulmonary embolism or aortic dissection.
- Laboratory markers that can be used to confirm the diagnosis of ACS include cardiac troponin levels, which are typically elevated in patients with myocardial infarction. Other tests, such as a complete blood count and metabolic panel, may also be performed to assess the patient’s overall health status and help guide treatment decisions.
Task 44
A 69-year-old patient is sent to a clinic by a district doctor with complaints of severe dyspnea during slight physical activity, suffocation attacks at night. Deterioration of patient’s condition is observed about a week before hospitalization.
In history: 6 years ago the patient was diagnosed with dilated cardiomyopathy. The patient took the following selected medication: Hypothiazid (12.5 mg a day), Fosinoprilum (20 mg a day), and Caverdilolum (12.5 mg twice a day). There was weakness during physical activity.
The patient reported that cough appeared and body temperature increased to 37.4°С several days ago after hypothermia. Due to increasing weakness, the patient stopped taking Caverdilolum and drank plenty of liquid and took vitamins. The patient’s condition got worse.
The patient’s weight is 76 kg and the height is 168 cm. Cyanosis. At auscultation: stagnant rale from both sides in the lungs; cardiac sounds are dull, rhythmic, protodiastolic gallop rhythm. Heart rate is 105 bpm. Arterial pressure is 105/70 mmHg. There is symmetrical edema of lower extremities.
Blood tests showed sodium 138 mmol/L and potassium 3.9 mmol/L.
ECG was performed with the following results: sinus rhythm, left bundle branch block, ventricular extrasystoles, QRS 0.13 sec.
Echocardiography was performed with the following results: diffuse hypokinesia of the left ventricular walls, ejection fraction 36%, left ventricular end diastolic volume 69 mm.
Task
1. Suppose the most likely diagnosis.
2. What caused the severe condition of the patient? What contributed to the development of heart failure decompensation? Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. What groups of medications should be administered to the patient? What decision should be made about the prescribed ACE inhibitor Fosinoprilum in connection with arterial pressure 105/70 mmHg (cancel, reduce or increase the dose)? What should be done about Carvedilol?
5. If, despite adequate therapy, it is impossible to achieve a stable compensation for heart failure, are there any other options for treatment?
1.Diagnosis: Dilated cardiomyopathy. Complete left bundle branch block. Rare ventricular extrasystole.
Chronic heart failure with reduced EF LVH (36%), stage II B, Functional Class IV.
2.what caused the severe conditions of this patient and justify the diagnosis
* According to the anamnesis, the diagnosis “dilated cardiomyopathy” was made to the patient 6 years ago (with ECHO-CG there is dilatation of the left ventricle, hypokinesia of the walls of the left ventricle). Currently, the severity of the condition is due to the phenomena of heart failure, the decompensation of which was facilitated by: viral infection, abundant fluid intake and drug withdrawal. The diagnosis of CHF and its stage are based on complaints (shortness of breath, dyspnea), objective data (cyanosis, edema of the lower extremities, wheezing in the lungs, protodiastolic gallop rhythm), the results of ECHO-KG (low left ventricular ejection fraction, left ventricular dilatation)
3.make and justify a plan for additional examination
* In addition to general clinical studies (general blood test, general urine analysis, biochemical blood test),kidney function test, liver function test (creatine level,BUN
* it is necessary to conduct an X-ray examination of the chest organs to exclude pneumonia, infiltrative lung diseases (the patient has an increase in body temperature, cough) in order to identify signs of cardiomegaly, signs of venous stasis in lungs, the presence of effusion in the pleural cavity;
* daily monitoring of ECG according to Holter in order to detect disturbances in the rhythm and conduction of the heart.
4.what group of medications should be administered to this patient and What decision should be made about the prescribed ACE inhibitor Fosinoprilum in connection with arterial pressure 105/70 mmHg (cancel, reduce or increase the dose)? What should be done about Carvedilol?
-The main groups of drugs for the treatment of this patient
* ACE inhibitors
* selective b-blockers
* diuretics (Hypothiazide, Furosemide)
* cardiac glycosides Digoxin (due to decompensation, large heart size and low left ventricular ejection fraction),
* antiplatelet agents (for the prevention of thromboembolic complications ).
### The ACE inhibitor fosinopril should be left to the patient in treatment, but the dose should be reduced due to low blood pressure. The ß-blocker Carvedilol should be re-prescribed to this patient .
5.despite adequate therapy it’s impossible to achieve a stable compensation for heart failure any other options for treatment
* If drug therapy is ineffective, electrophysiological and surgical methods of treatment are resorted to : two-chamber electrical stimulation of the heart using an implanted pacemaker (improves intracardiac hemodynamics, increases the systolic function of the ventricles, prevents the development of some complications); heart transplant. Indications for heart transplantation : rapid progression of CHF and lack of effect from the therapy; the occurrence of dangerous heart rhythm disturbances; high risk of thromboembolic complications.
** Additional information
- The most likely diagnosis for this patient is heart failure decompensation due to dilated cardiomyopathy, given the history of dilated cardiomyopathy and the symptoms of severe dyspnea, suffocation attacks, and edema of the lower extremities.
- The severe condition of the patient is likely caused by a worsening of the dilated cardiomyopathy, possibly triggered by the recent hypothermia and resulting in heart failure decompensation. The patient’s history of dilated cardiomyopathy, along with the presence of left bundle branch block, ventricular extrasystoles, and diffuse hypokinesia of the left ventricular walls seen on echocardiography, support this diagnosis.
- Additional examination of the patient should include laboratory tests to assess kidney function, electrolyte levels, and cardiac biomarkers, as well as imaging studies such as chest X-ray or CT scan to evaluate the extent of pulmonary congestion. A cardiac catheterization may also be considered to assess the degree of coronary artery disease and evaluate the patient’s candidacy for revascularization procedures.
- Medications that should be administered to the patient include diuretics to reduce fluid overload
Task 45
A 65-year-old patient, a pensioner, was admitted to the clinic with complaints of rare pulse, intermission, a feeling of heart fading and stopping, shortness of breath when climbing one flight of stairs, pressing pain behind the sternum during regular physical activity and brief loss of consciousness. The pain was relieved after 1-2 minutes after the patient took Nitroglycerin.
In history: the patient had a myocardial infarction 4 years ago. A year after, the patient developed anginal pain during normal physical activity. A week ago the patient felt intermissions, inspiratory dyspnea and noted brief loss of consciousness, which was the reason for hospitalization.
Objective clinical examination: the patient’s condition is of moderate severity, acrocyanosis, no edema. There is a small amount of non-sonorous fine bubbling rale in the lower parts of lungs. Cardiac sounds are muffled and non-rhythmic. Heart rate is 42 bpm. Pulse is 42 bpm. Arterial pressure is 110/65 mmHg.
The abdomen is soft and painless. The liver is 2 cm below the costal arch, its edge is smooth, rounded and slightly tender to palpation.
The ECG is recorded:
Task
1. Determine the syndromes and identify the main one.
2. Interpret the electrocardiogram.
3. Make a diagnosis.
4. Make a plan of additional examinations.
5. Prescribe treatment
1.Determine the syndromes and identify the main one
* Syndromes: rhythm and conduction disturbances, coronary insufficiency, chronic left ventricular failure.
Leading - a syndrome of rhythm and conduction disturbances .
2: interpretation of ECG
* Sinus rhythm, atrioventricular block II degree, Mobitz I (with Samoilov-Wenckebach periodicals)
3.Diagnosis
* Arteriosclerotic heart disease: angina pectoris, Functional Class III. Postinfarction cardio-
sclerosis.
Justification * angina pectoris because patient came in with pressing chest pain behind the sternum and it’s functional class III because patient losses consciousness,and he feels his heart fading and stopping with shortness of breath when climbing one flight of stairs , post MI sclerosis due to his anaemesis because patient had myocardial infarction for 4 years
4. Make a plan of additional examination
* General blood test,
* General urine test
* biochemical blood test (troponin T or I, glucose
* creatinine with the calculation of GFR, K, Na),
* dynamic ECG, coronary angiography
* echocardiography, chest X-ray.
*lipid profile
5. Prescribe treatment
* Urgent measures for an attack: put the patient to bed, provide fresh air, evaluate vital functions, ensure the removal of saliva
* Resuscitation measures (chest compressions and mechanical ventilation)
* according to indications. Shown is the implantation of a temporary, and subsequently - permanent pacemaker
* Taking into account the results of coronary angiography, determine the indications for myocardial revascularization (PCI (precutaneous coronary intervention)and / or coronary artery bypass grafting).
*Drug therapy should include the appointment of antiplatelet agents, statins, ACE inhibitors, after implantation of a pacemaker - β-blockers
Aspirin 300mg clopidogrel 300 mg, bisoprolol 10mg , statins (Atorvastatin 10-20mg)
Task 68
A 49-year-old patient complains of severe weakness, constant drowsiness, losing 6 kg in six months, gingival and nasal bleeding, abdominal distention, and itching. The patient’s condition is of moderate severity. In history: long-term alcohol abuse.
Examination was performed with the following results: jaundice of the skin, mucous membranes and sclera, vascular asterisks on the neck, chest, erythema Palmare, and Dupuytren’s contracture. There is atrophy of the muscles of the upper shoulder girdle, weight deficit (weight 58 kg with a height of 177 cm, BMI 17).
There are subcutaneous hematomas on the arms and legs.
There is abdomen distention. With percussion, there is fluid detected in the abdominal cavity.
The liver is palpated 4 cm below the costal arch, the edge is sharp and dense. The percussion dimensions are 13×11×6 cm. The percussion dimensions of the spleen are enlarged, 17×12 cm. Total protein 59 g/L, albumins 48%, globulins 52%, and gamma-globulins 28.5%.
Task
1. Suppose the most likely diagnosis.
2. Name the syndromes of internal organ damage.
3. Explain why you identified these syndromes.
4. Make a plan for additional examination of the patient and justify it.
5. What groups of medications should be administered to the patient?
1.diagnosis: Preliminary diagnosis: “liver cirrhosis (of toxic (alcoholic) origin), active phase, class “C”
by Child-Pugh (14 points) class c ,Decompensated portal hypertension ,varicose veins stage 1(spider veins ), Ascites grade 2, hepatoencephalopathy grade 2,hepatocellular insufficiency ,cholestatic syndrome,immune inflammatory syndrome,hemorrhagic syndrome
2.Name the syndromes of the internal organ
* Portal hypertension syndrome
* hepatocellular failure syndrome
* cholestatic syndrome
*hemorrhagic syndrome
*hepatoencephalopathy syndrome.
*Asthenovegetative syndrome
*cytolytic syndrome
3. Explain why you identified these syndromes
* The syndrome of portal hypertension is evidenced by an increase in the volume of the abdomen, the presence of effusion in the abdominal cavity with abdominal percussion, and an increase in the size of the spleen.,varicose veins ,
*The syndrome of hepatocellular failure :weight loss,skin changes ,muscle wasting and jaundice
* The cholestatic syndromeis manifested by the presence of itching, yellowness of the skin, sclera, mucous membranes.
* The presence of immune -inflammatory syndrome is evidenced by dysproteinemia, hypergammaglobulinemia, and enlarged spleen.
*cytolytic syndrome:weight loss,liver palms ,spider naevus ,fetor hepaticus
*Astenovegetative syndrome :fatigue drowsiness during the day and insomnia at night
*hemorrhagic syndrome: gingival bleeding,nasal bleeding and skin hemorrhages ,hematomas
4. Make a plan for additional examination and justify it
*Elastography method : fibroscan
*MRI is
* To confirm the diagnosis, it is necessary to perform fibroesophagogastroscopy with an assessment of the state of the veins of the esophagus and the cardiac part of the stomach, sigmoidoscopy with an assessment of the veins of the rectum,
* ultrasound examination (Doppler)of the abdominal organs to determine the size of the liver, its structure, the size of the spleen, the amount of ascitic fluid in the abdominal cavity and pleural cavities.
* . It is necessary to examine all functional liver tests ( ALAT, ASAT, bilirubin, prothrombin, cholesterol, alkaline phosphatase )
* a hemogram with the determination of the number of platelets
* perform a serological blood test for the presence of antibodies to hepatitis B, D and C viruses to exclude possible viral hepatotropic infections
* It is desirable to determine the level of alpha-fetoprotein to exclude hepatocellular carcinoma and the level of ferritin to exclude hemochromatosis of the liver.
Biopsy of liver
5. What groups of medications should be administered to the patient
* Non-selective beta blockers.
* Diuretics(furosemide 40mg)
* Albumin
* Hepatoprotectors
* Enzymes
* Prophylactic antibiotics
Spirinolactone 100 mg is the standard treatment
Ursodeoxychloric acid (15-20 mg per kg )for the itching skin
** Additional information
- The most likely diagnosis for this patient is cirrhosis of the liver.
- The patient presents with several syndromes of internal organ damage, including jaundice, vascular asterisks, erythema Palmare, Dupuytren’s contracture, atrophy of the muscles of the upper shoulder girdle, weight loss, subcutaneous hematomas, and abdominal distention with fluid detected in the abdominal cavity.
- These syndromes are indicative of liver damage, specifically cirrhosis, which is a chronic liver disease characterized by fibrosis and the formation of nodules that replace healthy liver tissue. The vascular asterisks, erythema Palmare, and Dupuytren’s contracture are all associated with cirrhosis and result from changes in the blood vessels and connective tissue in the body.
- Additional examination of the patient should include liver function tests, imaging studies such as ultrasound or CT scan of the abdomen, and a liver biopsy to confirm the diagnosis of cirrhosis and assess the extent of liver damage. The patient should also be screened for hepatitis B and C, as these infections can lead to cirrhosis.
- Medications that may be administered to the patient include diuretics to reduce fluid buildup in the abdomen, vitamin K to address bleeding, and lactulose to manage hepatic encephalopathy. The patient may also require treatment for alcohol addiction, as continued alcohol abuse can worsen liver function and lead to further complications. In advanced cases of cirrhosis, liver transplantation may be necessary.
Task 48
A 72-yes-old pensioner has come to the district doctor with complaints of headaches, dizziness, tinnitus aurium, increase of arterial pressure to 210/120 mmHg.
In history: two years ago arterial pressure increased, the patient took Metoprolol, Hypothiazid,
however, this did not result in significant decrease of arterial pressure. Within six months, the patient notes fatigue when walking, pain in the legs which makes him stop (when walking less than 200 m). The patient is hospitalized to clarify the cause of the condition and select medication. Objective clinical examination: the condition is satisfactory. There is no edema. There is percussion pulmonary sound over the entire surface of the lungs. During auscultation, respiration is vesicular, without rale. The heart region is visually normal.
The heart borders are the following: the right one is 1 cm outwards from the right edge of the sternum, the upper one is the 2nd rib, the left one is 1.5 cm outwards from the left midclavicular line in the 5th intercostal space. Apex beat is in the 5th intercostal space, outward from the midclavicular line, diffuse. Cardiac sounds are muffled and rhythmic. The second sound above the aorta, systolic murmur on the aorta without conducting on the neck vessels. Pulse is 76 bpm, rhythmic. The vascular wall beyond the pulse wave is dense. Arterial pressure is 195/115 mmHg. The abdomen is soft and painless. The liver is along the edge of the costal arch.
A systolic murmur is heard above the abdominal aorta.
CVA tenderness test is negative. The pulsation is reduced in the arteries of the back of both feet. Clinical blood test was performed with the following results: hemoglobin 145 g/L, RBC count 4.5×1012/L, WBC count 7.9×109/L, ESR 12 mm/h, CI 1.0.
General urinanalysis was performed with the following results: specific gravity 1020, protein 0.033 g/L, WBC - units/hpf, single hyaline casts.
Biochemical blood test was performed with the following results: blood sugar 5.2 mmol/L (3.5- 6.1), cholesterol 7.2 mmol/L (4.0), urea 9.0 mmol/L (2.4-8.3), creatinine 0.13 mcmol/L (0.014- 0.44), potassium 5.4 mmol/L (3.4-5.3), sodium 135 mmol/L (130-156).
Isotope radiography was performed with the following results: moderate decrease in secretory and excretory functions of the right kidney.
The examination of the eye fundus was performed with the following results: retinal vascular angiopathy.
Echocardiography was performed with the following results: right ventricle 2.1 cm (normal value 2.3), interventricular septum 1.25 cm (normal value 1.0 cm), left ventricle posterior wall 1.25 cm (normal value 1.0 cm), left ventricular end diastolic diameter 5.8 cm (normal value 5.5), left ventricular end systolic diameter 3.7 cm (normal value 3.5).
The ejection fraction is 54% (normal value 60-80%). There is calcification of the mitral and aortic valves.
An ECG is presented.
Task
1. Identify the main syndromes (explain pathophysiological mechanisms of their appearance).
2. Make a differential diagnostic series.
3. Make a diagnosis and justify it.
4. Make a plan of examinations to specify the diagnosis.
5. Make a treatment plan.
1.Identify the main syndromes and explain Pathophysiology
*syndrome of arterial hypertension: Elevated blood pressure must be due to elevated cardiac output, elevated peripheral vascular resistance, or a combination of both. Each of these mechanisms is regulated, in turn, by hemodynamic, neural, humoral, and renal processes, all of which vary in their contribution from one individual to another . the predominant cause of hypertension tends to be elevated peripheral vascular resistance, often in combination with increased stiffness of the vessels, which manifests itself clinically as isolated systolic hypertension
* syndrome of cardiomegaly, mainly of the left sections: The hallmark pathophysiologic feature of dilated cardiomyopathy is systolic dysfunction. Several pathogenetic mechanisms appear to be operative. These include increased hemodynamic overload, ventricular remodeling, excessive neurohumoral stimulation, abnormal myocyte calcium cycling, excessive or inadequate proliferation of the extracellular matrix, accelerated apoptosis, and genetic mutations.
* intermittent claudication syndrome .: Peripheral vascular disease is primarily driven by progressive atherosclerotic disease resulting in the reduction of major organ blood flow and end-organ ischemia. The process of atherosclerosis is complex, with the involvement of numerous cells, proteins, and pathways
2: Make a differential diagnosis
* hyper aldosteronism
* coarctation of aorta
* renal artery stenosis
*chronic kidney disease
### Common are signs of arterial hypertension (increased blood pressure, tinnitus,
dizziness), increased blood pressure.
However, for isolated systolic hypertension, the diastolic pressure figures should be within the normal range. An increase in systolic blood pressure in old age is associated with an increase in OPSS ( the vascular wall becomes “rigid”, the elasticity of the vascular wall is reduced ).
Hypertension is characterized by an earlier onset (45-50 years), a long history of arterial hypertension. For vasorenal hypertension - old age, persistent increase in blood pressure, vascular noise, increased blood plasma cholesterol levels.
3. Make a diagnosis
Artherosclerosis of the aorta, renal vessels. Possible renal artery stenosis on the right. Vasorenal hypertension, stage 3 arterial hypertension (SAP >160, DAP > 100). Left ventricular hypertrophy. Stage 3A chronic kidney disease. Hypercholesterolemia. Intermittent claudication, stage IIA ischemia. Risk of cardiovascular complications 4 (very
high).
Justification: The main diagnostic signs: the patient’s age (72 years), monotonously high hypertension, the presence of vascular murmurs ( signs of atherosclerosis of the aorta : accent of the second tone over the aorta, systolic murmur of the abdominal aorta, increased plasma cholesterol level ), pain, fatigue in the legs when walking up to 200 meters, forcing the patient to stop, a decrease in pulsation in the arteries of the rear of the feet.
4.Make a plan of examinations to specify the diagnosis
* If possible, determination of plasma renin (from the renal veins)
* Rehberg’s test (to determine the function of the kidneys);
* Ultrasound of the kidneys;
* Excretory urography (to reveal the delay of the nephrographic effect
* Lipidogram; Contrast aortography with renal artery angiography (to reveal the presence of renal artery stenosis).
5. Make a treatment plan
* diet with restriction of animal fats, salt
* statins ;Atorvastatin 10mg (stabilization of atherosclerotic plaques, hypocholesteric effect);
* Norvasc 10 mg once a day in the morning (vasodilation, nephroprotective properties);
* small doses of diuretics : Indapamide 1.25 mg (a thiazide-like diuretic with a vasodilating effect);
* aspirin 300mg clopidogrel 300mg prevention of thrombosis in blood vessels.
* Active detection of signs of coronary atherosclerosis (coronary angiography) and BCA atherosclerosis (CDS).
* Consultation with a vascular surgeon for diagnosis and determination of indications for surgical treatment (nephrectomy, or reconstructive surgery on the renal vessels - removal of atherosclerotic plaques from the renal arteries, or angioplasty).
Task 53
A 42-year-old patient, a housewife, has come to the district doctor with complaints of feeling general weakness for several years and a body temperature increase to subfebrile without any cause.
A month ago, after an acute respiratory disease, there appeared moderate pain and swelling of the 2nd and 3rd metacarpophalangeal joints, the 2nd, 3rd and 4th proximal interphalangeal joints of both hands; joint stiffness lasting for 3 hours in the morning.
Joint syndrome is accompanied by an increase of body temperature to 37.3°С.
The patient has difficulty doing the housework.
Objective clinical examination: the skin is of normal color and clean. Respiration is vesicular, without rale. The left border of relative cardiac dullness is along the midclavicular line. Cardiac sounds are rhythmic. Arterial pressure is 130/80 mmHg.
There is a defiguration of the abovementioned joints due to exudative and proliferative phenomena, diffuse painfulness, active and passive movements are limited and painful.
Clinical blood test was performed with the following results: WBC count 9.0×109/L, ESR 35 mm/ h.
Biochemical blood test showed that rheumatoid factor (RF) was 1:80.
Anti-cyclic Citrullinated Peptide Antibody (anti-CCP) 375.8 U/ml.
Hand radiograph was performed with the following results: periarticular osteoporosis, joint space narrowing, and single bone usuras.
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. What will be the treatment strategy for this disease?
5. What basic medication is advisable to prescribe in this case and why?
1.Diagnosis: Advanced erosive seropositive rheumatoid arthritis(because there is rheumatoid factor positive in blood), ACPAs+, moderate activity (DAS28=5.0), radiological stage II, functional class of joint insufficiency II. Advanced se- ropositive rheumatoid arthritis, ACPAs+, moderate activity (DAS28=5.0), erosive (radiolog- ical stage II), FC III.
2. Justify the diagnosis
* The diagnosis of “rheumatoid arthritis” was made on the basis of typical signs of articular syndrome: morning stiffness, swelling of the metacarpophalangeal and proximal interphalangeal joints. X-ray data of the hands: periarticular osteoporosis, narrowing of the joint space, usury. Detection of high numbers of rheumatoid factor, antibodies to cyclic citrullinated peptide and ESR. The activity of the process is determined using the DAS28 index. Functional deficiency class - due to the restriction of homework. It is advanced because she has been suffering the disease for several years and it’s seropositive because rheumatoid factor is positive in blood. Das28 is just a criteria for checking the 28 joints affected by rheumatoid arthritis which indicates the disease activity thus score 5.0 is moderate activity
3.make and justify additional examination plan for patient
* . The patient is recommended to have an X-ray examination of the lungs
* ultrasound examination of the abdominal cavity and kidneys
* EchoCG and ECG
* Determination of the general analysis of urine.
* Blood creatinine, ALT, AST, bilirubin
* Examination by an ophthalmologist, neurologist.
4. What will be the treatment strategy
* After examination, the patient needs to prescribe basic therapy - Methotrexate 15 mg per week, Folic acid 5 mg per week.
* To relieve pain, it is necessary to prescribe NSAIDs (for example, celecoxibs retard 400mg , or diclofenac 100mg 2 times a day), in combination with Omeprazole 20 mg 1 time a day.
*Because methotrexate takes time to kick in we can prescribe methotrexate + glucocorticoids for 2-3 months then Wait for the effectiveness of methotrexate then gradually reduce glucocorticoids and then stop it use alternating regimen of glucocorticoids
5.what basic medication is advised
* The first-line drug - Methotrexate, since this drug most effectively controls the autoimmune inflammatory process in RA, slows down the X-ray destruction of bone tissue, prevents the development of systemic manifestations of the disease, is well tolerated. But additional drug such as folic acid will help to prevent side effects of methotrexate
Task 54
Patient Yu., 53 years old, has come to the district doctor with complaints of weakness, pain throughout the spine (mainly at night), in both hip and knee joints, morning stiffness up to 40 minutes, which passed after exercise.
History: the patient has been ill since the age of 35, pain in the loin and sacrum (especially at night) appeared, then there appeared stiffness after a short morning exercise, and the body temperature increased to 37-37.5°С.
Objective clinical examination: the condition is satisfactory; the position is active. Arterial pressure is 150/100 mmHg. Heart rate is 74 bpm. Respiration rate is 18 brpm. Body temperature is 37.3°С.
There is a severe thoracic kyphosis and cervical hyperlordosis, smooth lumbar lordosis, pain during palpation along the spine, paravertebral lines and hip joints. Active and passive movements cause pain.
Tests were performed with the following results: Kushelevsky’s symptom I and II positive, Thomayer test - 65 cm, Forestier 22 cm, chin-chest test 5 cm, chest excursion test 100-96 cm (4 cm).
Radiograph of the spine and ileosacral joints was performed with the following results: deforming spondylosis, bilateral sacroiliitis, grade III.
Clinical blood test was performed with the following results: RBC count 4.2×1012/L, Hb 122 g/L, platelet count 220×109/L, WBC count 10×109/L, band neutrophils 1%, segmented neutrophils 63%, monocytes 4%, eosinophils 2%, lymphocytes 30%, ESR 18 mm/h.
Immunological tests were performed with the following results: C-reactive protein 5mg/L, negative rheumatoid factor.
General urinanalysis is within the range of normal limits.
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. What will be your treatment strategy for this disease?
5. What medications are more preferable for this patient taking into consideration
the extra-axial manifestations of the disease?
1.Diagnosis: Ankylosing spondylitis, late stage, moderate activity (BASDAI 3,2). Bilateral sacroiliitis, grade III. Bilateral coxarthrosis. Extra-axial manifestations (knee joint oligoarthritis). Functional Class III. Complications: cervical-thoracic kyphosis (occiput to wall distance - 22 cm)
2.Justify the diagnosis
* The diagnosis of “ankylosing spondylitis (AS)” was made on the basis of the inflammatory nature of the pain in the spine, changes in the corresponding clinical tests (Kushelevsky, Thomayer, Forestier) and the detection of ileosacral joints of stage III sacroiliitis on the radiograph. The extended stage was set on the basis of the duration of the course of the disease and the absence of ankylosis in various parts of the spine. The value of the BASDAI (Bath ankylosing spondylitis disease activity index is calculated based on 1: presence of HLA- B27,positive buttock pain which resolves with exercise and MRI and x ray evidence of sacroiliac involvement and BASFI indices based on the calculation of the corresponding medical calculators and used as a criteria to assess the progress of therapy of the disease . Functional joint failure was established on the basis of changes in the physiological curves of the spine and limitation of the spine’s mobility
3. Make and justify a plan for additional examination
* The patient is recommended to x-ray and ultrasound of the hip joints to determine the presence of coxitis in the patient.
* Examination by an ophthalmologist to identify the manifestation of eye damage.
* Performing an ECG and EchoCG to detect aortitis or other manifestations of the involvement of the heart in the pathological process.
* Determination of HLA-B27, antibodies from the major histocompatibility complex of human leukocytes to the B27 antigen, which indicate the genetic nature of the disease.
4. Treatment strategies
* All patients need the appointment of NSAIDs and exercise therapy.
* Taking NSAIDs should be constant and long-term. NSAIDs are basic drugs for the treatment of AS (for example, Diclofenac sodium 100 mg 2 times a day or Etoricoxib 90 mg 1 time a day).
* In the absence of the effect of taking NSAIDs - the decision on the appointment of tumor necrosis factor alpha inhibitors (Infliximab, Adalimumab, Golimumab).
* When the presence in the patient’s phenomena peripheral arthritis should be the appointment of sulfasalazine. With its ineffectiveness, the decision on the appointment of genetically engineered biological drugs from the group of tumor necrosis inhibitors alpha (TNF alpha), since
Task 55
A 64-year-old patient has come to the district doctor with complaints of swelling and pain in the right ankle joint and small joints of the right foot, redness of the skin above them, and restriction of movement in these joints.
History: the patient has been suffering from sudden pain attacks in right foot joints for about 8 years, when the patient was feeling relatively well and intense pain appeared in the first toe of the right foot at night. Further on, the arthritis repeatedly recurred. The pain in the right ankle joint appeared during the last six months. Repeatedly, yellowish brown concrements of up to 3-4 mm in size were removed with the urine.
Objective clinical examination: normal constitution, high-calorie diet. Near the cartilaginous part of the auricles, painless dense formations of 0.3x0.2 cm are palpated, the formations are whitish at the bend. There is bone deformation in the area of the 1st and 2nd metatarsophalangeal joints of the right foot, accompanied by swelling, skin reddening and increase of body temperature over the same joints. The right ankle joint is swollen and painful during palpation. The skin above the joint is shiny, of bluish purple color and hot. Arterial pressure is 170/105 mmHg. Heart rate is 84 bpm. The borders of relative cardiac dullness are extended to the left by 2 cm from the midclavicular line. Cardiac sounds are muffled and rhythmic.
Uric acid 780 mmol/L, blood cholesterol 6.7 mmol/L, triglycerides 2.7 mmol/L, HDL 1.0 mmol/L, glucose fasting 6.2 mmol/L, 2 hours after taking 75 g of glucose 6.4 mmol/L.
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. What will be your treatment strategy during the acute attack and between the attacks?
5. What medications are more preferable for the correction of the arterial hypertension and hypercholesterolemia? Why?
1.Diagnosis: Primary disease. Chronic tophaceous gout: acute oligoarthritis, nephrolithiasis; subcutane- ous tophi, hyperuricemia.
Concomitant disease. Essential hypertension (stage II: systolic 160 or greater, diastolic 100 or greater), arterial hypertension (grade II: 140-159/90-99). Left ventricular hypertrophy. Hyperlipidemia, hyperuricemia, obesity; risk 3. Target BP< 130/< 80 metabolic syndrome
2.justify the diagnosis
* The diagnosis of “gout” is made on the basis of typical signs of articular syndrome: paroxysmal inflammation of the joints of the foot, intense pain, swelling of the joints, in addition, the recurrent nature of the course and the presence of tofuses are important.The condition is chronic because patient has been suffering the disease for 8 years ,also presence of subcutaneous tophias we can see in the auricles, and finally hyperuricemia due to high level in blood (780mmol/l) normal range is 0.24-0.51mmol/l)
The diagnosis of hypertensive disease (HD) was established on the basis of the patient’s complaints of instability of blood pressure, the establishment of the degree of hypertension is based on the BP figures measured during admission.
The stage of hypertension is established based on the presence of damage to target organs (heart). The degree of risk of cardiovascular complications is based on the presence of metabolic syndrome.
The diagnosis of “metabolic syndrome” was established on the basis of obesity, hypertension, dyslipidemia patient has high cholesterol level in blood (6.7mmol/l. Normal cholesterol levels is 5.3mmol/l(an increase in the level of triglycerides and a decrease in the level of HDL), and fasting hyperglycemia.
Patient also had left ventricular hypertrophy due to the borders of the relative cardiac dulled are extended to the left by 2cm from the midclavicular line normal is 1cm
3.Make and justify a plan for additional examination of the patient
* The patient is recommended to x-ray examination of the feet
* polarization microscopy of synovial fluid to visualize uric acid crystals,
* ultrasound of the kidneys to determine kidney damage,
* daily monitoring of blood pressure to assess the stability of the increase in blood pressure, daily blood pressure profile
* conducting an ECG; echocardiography to assess myocardial wall thickness, diastolic and systolic function; laboratory test
* creatinine to determine GFR and stage CKD.
4. What will be your treatment strategy during acute attack and between the attacks
* All patients need to follow dietary recommendations (limiting foods containing purines (meat), limiting fat in foods
* prohibiting alcohol intake
* To relieve acute articular syndrome, 3 groups of drugs are used: NSAIDs (for example, Diclofenac 100 mg 2 times a day after meals), glucocorticosteroids (Diprospan 1.0 locally) or Colchicine 1 mg 3 times a day.
* In the interictal period: it is necessary to continue adhering to the diet, add Allopurinol 300 mg per day to therapy until uric acid normalizes, followed by a decrease in the dose to the maintenance dose - 100 mg per day, NSAIDs - for pain.
** first line for acute attack is colchicine 0.5 mg 3 times a day + diclofenac 100 mg
* in case of multiple joint lesions Glucocorticoids prednisone 40-60 mg systemic use on the first day and gradually reducing the dose 5 mg till you stop because of side effects
5. What medications are more preferable
*uricosuric drugs such as probenecid and benzbromarone
*Febuxostat(xanthine inhibitors)
*uricases (pegloticase)
* Antagonists of receptors to angiotensin II for the correction of blood pressure and Atorvastatin 10mg to reduce hyperlipidemia, since these drugs have a uricosuric effect.
* In addition, the choice of a drug from the group of angiotensin II receptor antagonists is based on its nephroprotective properties.
* From the same position, it is justified to use a drug from the group of ACE inhibitors as an antihypertensive agent. The most proven nephroprotective properties from the group of ACE inhibitors are possessed by Ramipril, from the group of angiotensin II receptor antagonists - Losartan.
Task 47
A 39-year-old man complains of dyspnea, palpitations and cough at a local doctor’s appointment.
The patient notes having slight dyspnea and periodic palpitation for 5 years. About a week ago, the patient got angina with high fever and cough. The night before going to the doctor, the patient could not sleep because of severe dyspnea, which aggravated in the horizontal position.
In adolescence, the patient often had angina which was accompanied by pain in large joints. The patient was observed by a neurologist for chorea.
Objective clinical examination: orthopnea, acrocyanosis; respiration rate is 28 brpm, edema of the lower extremities, with lifting apex beat. Pulse is weak, arrhythmic, 96 bpm.
According to auscultation, heart rate is 110 bpm. Arterial pressure is 100/60 mmHg. Body temperature is 37.4 °С. The liver is enlarged and slightly painful during palpation.
With percussion, the heart is enlarged to the left and right. There is fine bubbling rale in the lower parts of the lungs.
At heart auscultation, there is arrhythmia with no periods of regular rhythm. In the apex, there is a three-part melody with a low dull additional component, the second sound is on the pulmonary artery. A three-part melody is auscultated in Botkin-Erb’s point. There is systolic and protodiastolic murmur at the apex. At the apex systolic murmur increases at exhalation and is conducted to the axillary region.
Clinical blood test was performed with the following results: ESR 32 mm/h, WBC count 11300 in 1 mm3.
Biochemical blood test showed C-reactive protein (++++). Diphenylamine test is 0.500 (N up to 0.200).
Task
1. Your tentative diagnosis.
2. Criteria for the main diagnosis.
3. What complications of the underlying disease do you suppose?
4. Make a plan for additional examination of the patient and justify it. 5. What is the treatment strategy and choice of medication?
1.Diagnosis: Recurrent rheumatic fever: carditis. Combined heart disease: stenosis and mitral insufficien- cy. Atrial tachysystole. Chronic heart failure stage IIB, Functional Class IV. Cardiac asthma.Hepatomegaly
2.criteria for the main diagnosis
* The patient has a rheumatic history, clinical and laboratory data, indicating the activity of the rheumatic process against the background of the transferred sore throat. The data of an objective examination and auscultation of the heart indicate the formation of a combined mitral heart disease: stenosis and insufficiency of the mitral valve. The nature of the pulse, the presence of a pulse deficit indicate atrial , mitral valves is usually associated with rheumatic fever,the murmurs is a typical description of the case
*Patient also has chorea when he visited the neurologist
* chronic heart insufficiency due to presence of symptoms such as edema,bubbling rales in the lower lungs
* in the laboratory results we can see see increased ESR 32mmhr, C-reactive proteins (++++)
*Patient also had arthragias which is indicative of this disease
*cardiac asthma; Cardiac asthma is not a form of asthma. It’s a type of coughing or wheezing that occurs with left heart failure. Depending on how severe the symptoms are, this wheezing can be a medical emergency. Heart failure can cause fluid to build up in the lungs (pulmonary edema) and in and around the airways.
3. What complications of the underlying disease do you suppose
* Bacteria endocarditis
* stroke can develop from atrial fibrillation
*ruptured heart valves and formation of vegetations on the valves
4. Make a plan for additional examination of the patient and justify it
* The patient is recommended: to identify the presence of streptococcal infection - a smear from the throat for bacteriological examination, determination of the ASL-O titer in the blood serum;
* to determine the nature of the organic lesion of the mitral valve, to assess the degree of mitral stenosis and mitral insufficiency.
* To assess the nature of the remodeling of the left ventricle, left atrium, right ventricle and right atrium by transthoracic echocardiography.
* Exclude the presence of thrombi in the atria by transesophageal echocardiography.
* Perform a chest x-ray.
5.what is the treatment strategy and choice of medication
* Antibiotic therapy. long-acting penicillin G benzathine An injection of 0.6-1.2 million units administered intramuscularly (IM) every 28 days rather than other regimens.
* Non-steroidal anti-inflammatory drugs
* To control the heart Digoxin is prescribed
*Aspirin 300 mg and clopidogrel 300mg for prevention of stroke
* With a decrease in the ejection fraction - Bisoprolol or Carvedilol, Spironolactone, ACE inhibitors (Enalapril or Lisinopril), a loop diuretic (Torasemide or Furosemide).
* For the relief of cardiac asthma - intravenous administration of nitrates. Consultation with a cardiac surgeon.
* Surgical treatment - mitral valve replacement - is indicated after the activity of the rheumatic process subsides and the degree of circulatory failure decreases.
Task 56
A 65-year-old retired woman has come to the district doctor with complaints of pain in knee and hip joints, distal interphalangeal hand joints, and in the lumbar spine, which appears during physical activity and moving. The pain appears more often in the evening and passes at rest. The patient also feel morning stiffness lasting up to 20 minutes. The patient cannot determine for how long she has been ill. The patient notes a gradual increase, during 5-7 years, of the abovementioned pain in the listed joints and lumbar spine. Previously the patient was neither examined nor treated. For the last 20 years, the patient has been working as a cleaner at school as she continues working in retirement. The patient notes frequent intense physical activity. Objective clinical examination: the patient is 160 cm tall and weighs 80 kg. The skin is of flesh colored with high humidity. There is no edema. The knee joints are deformed. The skin above these joints is of normal color. The body temperature is regular there. There is a slight restriction of joint movement due to painfulness. There is crepitus in the knee joints during active movements. There is pain during palpation and restriction of movement of the distal interphalangeal joints. The joints are shown in the picture below. The other joints are not changed. During palpation, the patient feels pain in the spinous and transverse processes of the lumbar spine. The movement is restricted there due to painfulness.
Respiration is vesicular, without rale. Pulse is rhythmic, satisfactory and tense, 78 bpm.
Arterial pressure is 135/80 mmHg. The borders of relative cardiac dullness are within the normal range.
Cardiac sounds are muffled and rhythmic, without noise. The abdomen is soft and painless. Clinical blood test was performed with the following results: hemoglobin 130 g/L, WBC count 6.7×109/L, eosinophils 3%, band neutrophils 4%, segmented neutrophils 57%, lymphocytes 30%, monocytes 6%, ESR 20 mm/h.
Knee radiograph was performed with the following results: joint space narrowing, subchondral
sclerosis, and marginal osteophytes.
Hand radiograph was performed with the following results: multiple osteophytes of distal interphalangeal joints, moderate joint space narrowing, osteosclerosis.
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. Make a treatment plan for this patient. Justify your answer.
5. Determine the prognosis of the disease and the patient’s ability to work.
1.Diagnosis: Primary disease: primary generalized osteoarthritis: bilateral gout, grade 3 according to the Kellgren-Lawrence grading system, bilateral coxarthrosis, arthrosis of distal interphalangeal joints of the hands (DIP joints), secondary synovitis of DIP joints and knee joints. Underly- ing condition: class 1 obesity (BMI - 31)
2.justify the diagnosis:
* Osteoarthritis: mechanical pain, stiffness within 20 minutes, deformation of the joints for
account of bone growths. X-ray stage: narrowing of the joint space, osteophytes, osteosclerosis.
Functional class: difficulty in professional activity. Obesity I degree (BMI - 31.3 kg / m 2 ).
3. Make and justify a plan for additional examination for the patient
* The patient is recommended: to clarify the degree of activity - determination of acute phase parameters (fibrinogen, CRP, proteinogram).
* X-ray of the lumbar spine
* Ultrasound of the knee joints (additional examination of the musculoskeletal system).
4. Make a treatment plan for this patient and justify the answer
* Basic therapy (chondroprotectors) - chondroitin sulfate 500mg 2 time a a day glucosamine sulfate 1500mg two times a day, Dona, Structum, Artra, Alflutop).
* NSAIDs (Movalis, Naproxen, Nimesulide).
* HA intra-articular in the presence of synovitis.
Intra-articular hyaluronic acid preparations.
* Antiplatelet agents and antagonists of Ca to improve microcirculation in the subchondral parts of the bones and in the synovium
* Exercise therapy, massage, physiotherapy (magnetotherapy, UHF, ultrasound).
Local therapy (NSAIDs, Dimexide) Treatment of concomitant diseases (correction of body weight).
Spa treatment.
##It is forbidden to walk for a long time, standing for a long time, carrying weights; frequent ascents and descents of stairs are not recommended.
5. Determine the prognosis of the disease and the patient ability to work
* Life prognosis is favorable. Possible disabling damage to the knee and hip joints. At the time of exacerbation - temporary disability.
Task 57
A 35-year-old woman, an accountant, has come to the district doctor with complaints of general malaise, weakness, weight loss of 5 kg in 3 months, migratory pain in the interphalangeal hand joints and ankle joints, irregular red spots on the face, and subfebrile body temperature. The patient considers herself ill for about 6 months. The disease onset is gradual. There were pain in the interphalangeal joints, swelling and hyperemia, alternately on the right and left hands.
Weakness and malaise appeared gradually. The patient did not seek medical help. Two months ago she was on vacation in Thailand. Upon return, the patient noted a deterioration in her health, which involved an increase of weakness, accompanied by pain in ankle joints. The patient lost weight for no apparent reason. The body temperature increased to 37.5°С without shivering. The patient noted red spots on her face and for a long period of time considered them to be the consequences of sunburn. During the next scheduled medical examination, anemia and changes in the urine were detected, and therefore the patient came to the district doctor.
Objective clinical examination: skin and visible mucous membranes are pale, red rash on the bridge of the nose and cheeks of irregular shape, hair is dull, brittle with areas of alopecia. Subcutaneous fat is almost absent. There is no edema. Submandibular, axillary and inguinal lymph nodes are palpated 0.5-1cm in diameter. Their consistency is soft. The lymph nodes are not tender to palpation. Muscle tone and strength are normal, the same on both sides. The parts of the skeleton are proportional, the bones are painless when palpated and tapped. There is swelling proximal and distal interphalangeal hand joints and ankle joints, painful during moving, with local hyperemia. The thorax is normosthenic, symmetrical and evenly moves during breathing. With percussion, there is a clear pulmonary sound over the lungs. Respiration is vesicular, without rale. Pulse is rhythmic, 78 bpm. Arterial pressure is 120/80 mmHg. Apex beat is not detected visually and during palpation. The borders of relative cardiac dullness are the following: the right one is 0.5 cm from the right edge of the sternum; the upper one is the lower edge of the 3rd rib; and the left one is 1 cm inwards to the midclavicular line.
During auscultation, cardiac sounds are muffled and rhythmic. Heart rate is 78 bpm. There is edema and hyperemia of the vermilion border. The abdomen is symmetrical, soft and painless in all the regions during surface and deep palpation. The liver is not enlarged. CVA tenderness test is negative on both sides, the kidneys are not palpated, palpation in their projection is painless. Clinical blood test was performed with the following results: hemoglobin 100 g/L, RBC count 2.9×1012/L, CI 0.9, WBC count 2.7×109/L, eosinophils 4%, band neutrophils 3%, segmented neutrophils 52%, lymphocytes 35%, monocytes 6%, ESR 30 mm/h, platelet count 98×10%. General urinanalysis was performed with the following results: light yellow, clear, acidic pH, specific gravity 1016, protein 0.3 g/L, glucose negative, WBC 1-2/hpf, renal epithelium 2-4/hpf, RBC 3-4/hpf, hyaline casts 5-8/lpf, waxy casts 2-3/lpf, urine sodium negative.
Biochemical blood test was performed with the following results: total bilirubin 38.8 mcmol/L, direct bilirubin 8.2 mcmol/L, indirect bilirubin 30.6 mcmol/L, creatinine 0.09% mmol/L, glucose 4.3 mmol/L, AST 10.0 mmol/L, ALT 19.0 mmol/L, cholesterol 4.0 mmol/L, potassium 3.9 mmol/ L, total protein 86 g/L, albumins 45%, α1 3.5%, α2 10.5%, β 13,6%, γ 27.4%, fibrinogen 6.2 g/L, C-reactive protein + + +, seromucoid 0.32 g/L.
There were antibodies to DNA, antinuclear factor, LE-cells 6 per 1000 WBC detected.
ECG was performed with the following results: sinus rhythm, heart rate 64 bpm. The electric axis is tilted to the left. There are diffuse dystrophic changes in the left ventricular myocardium.
Chest radiograph did not reveal any pathology.
Hand and ankle radiograph did not show any pathology.
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make and justify a plan for additional examination of the patient.
4. Make a treatment plan for this patient. Justify your answer.
5. Determine the prognosis of the disease and the patient’s ability to work.
1.Diagnosis: Subacute systemic lupus erythematosus (Subacute cutaneous lupus erythematosus (SCLE) is a nonscarring, non–atrophy-producing, photosensitive dermatosis. SCLE commonly develops in sun-exposed areas, including the upper back, shoulders, extensor arms, neck, and upper torso, while the face is often spared), high activity (SLEDAI - 12 points): polyarthritis, photosensitization, skin and appendage damage (butterfly-shaped rash on the face, cheilitis, alopecia) nephritis, CKD?, hematological disorders (thrombocytopenia, leukope- nia, mild normochromic hemolytic anemia?), anti-DNA+
2. Justify the diagnosis
* The diagnosis was made on the basis of the identified syndromes: cutaneous, articular, febrile, lymphadenopathy, anemic, urinary.
3. Make and justify a plan for additional examination
* The patient is recommended:
-EchoCG (detection of heart damage);
* determination of GFR by calculation method (determination of chronic renal failure and chronic kidney
disease
* kidney biopsy (gold standard of diagnosis).
* Immunoblogging for systemic immune markers, Sm antigen, antiphospholipid antibodies
4. Make a treatment plan for this patient and justify your answer
* Hospitalization in a specialized department.
* A diet high in polyunsaturated fatty acids, calcium, vit. D.
* Hydroxychloroquine 200-400mg daily is the cornerstone of lupus therapy. Methylprednisolone pulses followed by low–medium doses of prednisone rapidly control most moderate– severe flares.
* Cytotoxic drugs (cyclophosphamide 1 g / m 2 bolus per month for at least 6 months, or methotrexate 15 mg / week s.c.), HA (high dose pulse therapy),
* NSAID, plasmapheresis, genetically engineered biologicals (Rituximab or Orensakh).
5. Determine the prognosis of the disease and patient’s ability
* The prognosis is relatively favorable: it is possible to achieve stable clinical and laboratory remission with lifelong maintenance therapy.
It is necessary to define the disability group (II)
Task 58
A 44-year-old woman, a programmer, was admitted to the Department of Internal Medicine with complaints of increasing general weakness, pain, restricted movement and numbness mainly of fingers on both hands, slight dry cough, palpitation during physical activity, decreased appetite,dry mouth, and difficulty chewing and swallowing.
The patient considers herself ill since the age of 32 when after severe hypothermia she began to notice numbness of fingers on both hands during washing. Then the duration of numbness gradually increased. It began to occur even with a slight decrease in the atmospheric temperature. At the same time, the patient developed increased sweating in both palms. Over six months, the patient gradually developed general weakness, decreased appetite, which was the reason the patient came to the district clinic. Clinical blood test was performed as well as chest radiograph, FGD, however, the cause of asthenization was not found. Numbness of the fingers persisted. Gradually the patient developed a restriction of finger mobility and pain in the nail phalanges of the hands.
At a second examination a year later, the patient was diagnosed with rheumatoid arthritis. The patient was prescribed Prednisolone 20 mg a day, which stopped the pain, but did not relieve numbness in the hands. The patient decided to stop taking Prednisolone on her own. At the age of 42, after exposure to the sun, the patient began to notice difficulty swallowing, dry cough and palpitations when walking. In the last six months, the pain in the nail phalanges has greatly aggravated when the patient tried to type on a computer keyboard.
Objective clinical examination: the skin is evenly hyperpigmented. The skin of the hands and fingers is cold, hard, evenly thick. The skin cannot be taken in a fold. There are no wrinkles above the interphalangeal joints. The nail phalanges of all fingers are shortened. The muscles of the shoulder and pelvic girdle are atrophic. The muscles of the forearms are dense and rigid. The range of motion (both passive and active) is sharply reduced in the interphalangeal joints. Respiration is shallow, respiration rate is 24 brpm. There is a decrease in the lung function and symmetrical weakening of the vesicular breathing in the lower parts. Arterial pressure is 110/70 mmHg. The cardiac sounds are arrhythmic, 88 bpm, with single extrasystoles; the first sound above the apex and base of the xiphoid process is diminished. The abdomen is soft and painless to surface and deep palpation.
Clinical blood test was performed with the following results: RBC count 3.1×1012/L, hemoglobin 95 g/L, CI 0.85, WBC count 15.3×109/L, eosinophils 2%, band neutrophils 8%, segmented neutrophils 72%, lymphocytes 17%, monocytes 1%, ESR 27 mm/h.
Biochemistry blood test was performed with the following results: total protein 75 g/L, albumins 40%, globulins 60%, 1 - 3.8%, 2 - 12%, 32.2%, fibrinogen 6.6 g/L, C-reactive protein (++). Repeated studies of LE cells in blood are negative.
Chest radiograph was performed with the following results: a honeycomb lung, pneumosclerosis, mainly in the lower zones.
Hand radiograph: osteolysis of the distal phalanges and epiphyseal osteoporosis.
Attachment:
Patient’s ECG:
Task
1. Suppose the most likely diagnosis.
2. Justify the diagnosis.
3. Make a plan for additional examination of the patient and justify it.
4. Determine the treatment plan for this patient. Justify your answer.
5. Determine the prognosis of the disease and the patient’s ability to work.
1.Diagnosis: Chronic generalized systemic sclerosis, active phase II, limited form: Raynaud syndrome, induration and hyperpigmentation of skin, telangiectasias, pathology of esophagus, articular muscle syndrome with contractures, acro-osteolysis, diffuse fibrosing alveolitis with the
formation of a cellular lung. Respiratory failure?; old myocardial infarction (chronic pulmo- nary heart?), complete right bundle branch block, extrasystole. Chronic heart failure, stage I. anemia
2.justify the diagnosis
* The diagnosis was made on the basis of the identified syndromes: Raynaud’s syndromes, scleroderma, articular, dysphagia, respiratory failure, anemic, immune disorders
3. Make an additional plan for examination
* The patient is recommended (to confirm and clarify the diagnosis): wide-field capillaroscopy of the nail bed,
* immunogram,
* R-graphy of the esophagus with contrast,
* skin biopsy,
* EchoCG, CM ECG, FVD, FGDS, fundus, antibodies to DNA, ANF, aticenter antibodies, anti Scl 70
*coagulogram
*Blood biochemistry
*Immunological studies
4. Determine treatment plan
* Treatment of vascular complications: calcium antagonists , nifedipine 30-120 mg a day (Amlodipine 5-20 mg a day), Pentoxifylline 400mg , Losartan 25-100 mg / day;
* for the healing of digital ulcers - Prostaglandin E(6-10 ng/kg), Sildenafil (Viagra)
* suppression of the progression of fibrosis: D-penicillamine 250-500 mg / day;
* if interstitial lung disease is confirmed, then combination therapy with Prednisolone + Cyclophosphamide; given the defeat of the esophagus, fractional meals are necessary, the last meal is no later than 18 hours,
* with severe dysphagia - Metoclopramide 10 mg 3-4 r / day, in the presence of reflux esophagitis - Omeprazole 20 mg / day.
Spa treatment is contraindicated
* Massage, exercise therapy in the absence of disease activity. The prognosis is poor, associated with visceral lesions.
5. Determine the prognosis of the disease and the patients ability to work
* The patient is incapacitated, the definition of a disability group (II) is required.
